Tjahjadi Andy Kusumo, DDS

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

49917 Issued in CA

Practice address

501 N Brookhurst St Ste 100
Anaheim, CA 92801-5202

Phone

(714) 392-8283

Fax

(888) 498-3823

NPI assigned

Feb 26, 2007

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Tjahjadi Kusumo-Rahardjo Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Andy Kusumo DDS Inc

  • General Practice Dentistry
  • Anaheim, CA
  • NPI 1255721254
  NPD (past) Authorized official

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

{
    "created_epoch": "1172448000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1755216000000",
    "number": "1245366020",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "222 S EMERALD ST",
            "city": "ANAHEIM",
            "state": "CA",
            "postal_code": "928042525",
            "telephone_number": "949-769-0495",
            "fax_number": "714-400-2085"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "501 N BROOKHURST ST STE 100",
            "city": "ANAHEIM",
            "state": "CA",
            "postal_code": "928015202",
            "telephone_number": "714-392-8283",
            "fax_number": "888-498-3823"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "222 S Emerald St",
            "address_purpose": "LOCATION",
            "city": "Anaheim",
            "state": "CA",
            "postal_code": "928042525",
            "country_code": "US",
            "telephone_number": "949-769-0495",
            "fax_number": "714-400-2085",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "KUSUMO",
        "first_name": "TJAHJADI",
        "middle_name": "ANDY",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2007-02-26",
        "last_updated": "2025-08-15",
        "certification_date": "2025-08-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "CA",
            "license": "49917",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DENTIST",
            "identifier": "D49917",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "TJAHJADI",
            "last_name": "KUSUMO-RAHARDJO",
            "credential": "DDS",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Christine Kupelian
• Ana Kupenov
• Norah Biju Kurian
• Jacqueline Kurniawan
• Mark Kurosaki
• George M Kusztyk, OD
• Joseph D Kuwahara, MD
• KW Youn DDS Dental Corporation
• Aeri Kwak
• Angela J Kwak, O.D.

• General Practice Dentistry in Anaheim, CA
• Providers in Anaheim, CA by specialty
• General Practice Dentistry in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 15, 2025; 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.