MEDICARE: ANDRE WIDODO DDS A PROFESSIONAL CORPORATION

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	261QD0000X	Dental Clinic/Center	46152	CA

General Provider Information

NPI Number	:	1447583661
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANDRE WIDODO DDS A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	11635 VALLEY BLVD STE E
Second Line	:
City	:	EL MONTE
State	:	CA
Zip	:	91732-3071
Country	:	US
Telephone Number	:	626-444-7645
Fax Number	:	626-444-7628

Provider Business Practice Location Address
First Line	:	11635 VALLEY BLVD STE E
Second Line	:
City	:	EL MONTE
State	:	CA
Zip	:	91732-3071
Country	:	US
Telephone Number	:	626-444-7645
Fax Number	:	626-444-7628

Authorized Official
Title or Position	:	DENTIST / OWNER
Name	:	ANDRE WIDODO
Credential	:	DDS
Telephone Number	:	626-444-7645

Provider Enumeration Date	:	09/08/2009
Last Update Date	:	09/08/2009

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