MEDICARE: HERMAN BUDIMAN D.D.S.

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	1223G0001X	General Practice Dentistry	34067	CA

General Provider Information

NPI Number	:	1881777605
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HERMAN BUDIMAN D.D.S.

Provider Business Mailing Address
First Line	:	11635 VALLEY BLVD
Second Line	:	SUITE #E
City	:	EL MONTE
State	:	CA
Zip	:	91732-3071
Country	:	US
Telephone Number	:	626-443-8744
Fax Number	:	626-443-8903

Provider Business Practice Location Address
First Line	:	11635 VALLEY BLVD
Second Line	:	SUITE #E
City	:	EL MONTE
State	:	CA
Zip	:	91732-3071
Country	:	US
Telephone Number	:	626-443-8744
Fax Number	:	626-443-8903

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	07/08/2007

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