NPIMap

Organization Active NPI

Sulaeman Professional Dental, Inc.

  • General Practice Dentistry
  • San Bernardino, CA
National Provider Identifier
1063537538
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
License
37166 Issued in CA
Legal business name
SULAEMAN PROFESSIONAL DENTAL, INC.
Practice address
25054 Base Line St
San Bernardino, CA 92410-4026
Phone
(909) 889-9591
Fax
(909) 889-8721
NPI assigned
Mar 21, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Audrey Indhira Sulaeman, D.D.S
Title
Dentist
Phone
(909) 889-9591

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193400000X SINGLE SPECIALTY GROUP 1223G0001X 37166 CA Primary

Addresses

Primary practice location

25054 Base Line St
San Bernardino, CA 92410-4026

Mailing address

25054 Base Line St
San Bernardino, CA 92410-4026
Phone (909) 889-9591

Other identifiers 3

IdentifierTypeStateIssuer
D37166MedicaidCA
D44254MedicaidCA
D48030MedicaidCA

Other names 1

  • WIJAYA SULAEMAN, D.D.S. Other name

National Provider Directory

National Provider Directory

Locations

25054 Base Line St
Sn Bernrdno, CA 92410
Phone (909) 889-9591

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1174435200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1063537538",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "25054 BASE LINE ST",
            "city": "SAN BERNARDINO",
            "state": "CA",
            "postal_code": "924104026",
            "telephone_number": "909-889-9591",
            "fax_number": "909-889-8721"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "25054 BASE LINE ST",
            "city": "SAN BERNARDINO",
            "state": "CA",
            "postal_code": "924104026",
            "telephone_number": "909-889-9591",
            "fax_number": "909-889-8721"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SULAEMAN PROFESSIONAL DENTAL, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-21",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "SULAEMAN",
        "authorized_official_first_name": "AUDREY",
        "authorized_official_middle_name": "INDHIRA",
        "authorized_official_title_or_position": "DENTIST",
        "authorized_official_telephone_number": "909-889-9591",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.D.S"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, General Practice",
            "state": "CA",
            "license": "37166",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "D37166",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "D44254",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "D48030",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "WIJAYA SULAEMAN, D.D.S.",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in San Bernardino, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.