Wijaya Sulaeman, D.d.s. | |
25054 Base Line St San Bernardino CA 92410-4026 | |
(909) 889-9591 | |
(909) 889-8721 |
Full Name | Wijaya Sulaeman, D.d.s. |
---|---|
Speciality | Dentist - General Practice |
Location | 25054 Base Line St, San Bernardino, California |
Authorized Official Name and Position | Audrey Indhira Sulaeman (DENTIST) |
Authorized Official Contact | 9098899591 |
Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
Mailing Address | Practice Location Address |
---|---|
Wijaya Sulaeman, D.d.s. 25054 Base Line St San Bernardino CA 92410-4026 Ph: (909) 889-9591 | Wijaya Sulaeman, D.d.s. 25054 Base Line St San Bernardino CA 92410-4026 Ph: (909) 889-9591 |
NPI Number | 1063537538 |
---|---|
Provider Enumeration Date | 03/21/2007 |
Last Update Date | 08/22/2020 |
Identifier | Type | State | Issuer |
---|---|---|---|
1063537538 | NPI | - | NPPES |
D37166 | Medicaid | CA | |
D44254 | Medicaid | CA | |
D48030 | Medicaid | CA |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
1223G0001X | Dentist - General Practice | 37166 (California) | Primary |
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