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NPI Code Detail

MEDICARE: DR. WIJAYA SULAEMAN D.D.S., M.A.G.D.

MEDICARE: DR. WIJAYA SULAEMAN D.D.S., M.A.G.D.
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
11223G0001XGeneral Practice Dentistry37166CA

General Provider Information

NPI Number : 1932101706
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. WIJAYA SULAEMAN D.D.S., M.A.G.D.
Provider Business Mailing Address
First Line : 25054 BASE LINE ST
Second Line :
City : SAN BERNARDINO
State : CA
Zip : 92410-4026
Country : US
Telephone Number : 909-889-9591
Fax Number : 909-889-8721
Provider Business Practice Location Address
First Line : 25054 BASE LINE ST
Second Line :
City : SAN BERNARDINO
State : CA
Zip : 92410-4026
Country : US
Telephone Number : 909-889-9591
Fax Number : 909-889-8721
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/11/2005
Last Update Date : 07/08/2007

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