MEDICARE: H. HADIDJAJA, DDS INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	41834	CA

General Provider Information

NPI Number	:	1063815256
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	H. HADIDJAJA, DDS INC.

Provider Business Mailing Address
First Line	:	3122 E FLORENCE AVE
Second Line	:
City	:	HUNTINGTON PARK
State	:	CA
Zip	:	90255-5830
Country	:	US
Telephone Number	:	323-588-0001
Fax Number	:	999-999-9999

Provider Business Practice Location Address
First Line	:	3122 E FLORENCE AVE
Second Line	:
City	:	HUNTINGTON PARK
State	:	CA
Zip	:	90255-5830
Country	:	US
Telephone Number	:	323-588-0001
Fax Number	:	999-999-9999

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. HAMI HADIDJAJA
Credential	:	D.D.S.
Telephone Number	:	323-588-0001

Provider Enumeration Date	:	10/01/2014
Last Update Date	:	10/01/2014

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