Andre Widodo DDS a Professional Corporation

Primary specialty

Dental Clinic/CenterTaxonomy code 261QD0000X

License

46152 Issued in CA

Legal business name

ANDRE WIDODO DDS A PROFESSIONAL CORPORATION

Practice address

11635 Valley Blvd Ste E
El Monte, CA 91732-3071

Phone

(626) 444-7645

Fax

(626) 444-7628

NPI assigned

Sep 8, 2009

Last updated

Sep 8, 2009By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Andre Widodo, DDS

Title

Dentist / Owner

Phone

(626) 444-7645

Specialties & licenses 1

Addresses

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

{
    "created_epoch": "1252368000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1252368000000",
    "number": "1447583661",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11635 VALLEY BLVD STE E",
            "city": "EL MONTE",
            "state": "CA",
            "postal_code": "917323071",
            "telephone_number": "626-444-7645",
            "fax_number": "626-444-7628"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11635 VALLEY BLVD STE E",
            "city": "EL MONTE",
            "state": "CA",
            "postal_code": "917323071",
            "telephone_number": "626-444-7645",
            "fax_number": "626-444-7628"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ANDRE WIDODO DDS A PROFESSIONAL CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-09-08",
        "last_updated": "2009-09-08",
        "status": "A",
        "authorized_official_last_name": "WIDODO",
        "authorized_official_first_name": "ANDRE",
        "authorized_official_title_or_position": "DENTIST / OWNER",
        "authorized_official_telephone_number": "626-444-7645",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": "CA",
            "license": "46152",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Dental Clinic/Center in El Monte, CA
• Providers in El Monte, CA by specialty
• Dental Clinic/Center in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 8, 2009; 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.