Andre Widodo, DDS

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

46152 Issued in CA

Practice address

2112 S Garey Ave Ste a
Pomona, CA 91766-5600

Phone

(909) 590-5600

Fax

(909) 590-5606

NPI assigned

Feb 20, 2007

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Locations

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.

• Lee & Widodo DDS Inc

  • General Practice Dentistry
  • Chino, CA
  • NPI 1184972135
  NPD Authorized official
• Widodo & Lee DDS a Professional Dental Corp

  • Dental Clinic/Center
  • Pomona, CA
  • NPI 1245589282
  NPD Authorized official
• Lee & Widodo DDS Inc

  • Dental Clinic/Center
  • Pomona, CA
  • NPI 1841547775
  NPD

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

{
    "created_epoch": "1171929600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1650844800000",
    "number": "1508901257",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2112 S GAREY AVE STE A",
            "city": "POMONA",
            "state": "CA",
            "postal_code": "917665600",
            "telephone_number": "909-590-5600",
            "fax_number": "909-590-5606"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2112 S GAREY AVE STE A",
            "city": "POMONA",
            "state": "CA",
            "postal_code": "917665600",
            "telephone_number": "909-590-5600",
            "fax_number": "909-590-5606"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "5562 Philadelphia St Ste 103",
            "address_purpose": "LOCATION",
            "city": "Chino",
            "state": "CA",
            "postal_code": "917102482",
            "country_code": "US",
            "telephone_number": "909-670-1100",
            "fax_number": "909-398-0026",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WIDODO",
        "first_name": "ANDRE",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-02-20",
        "last_updated": "2022-04-25",
        "certification_date": "2022-04-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "CA",
            "license": "46152",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DENTIST",
            "identifier": "1184972135",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Helena Whitney
• Kellie Kristina Whittet, B.S. PSCYHOLOGY
• Alexandra Karras Whittle
• Andrew Whynaught, PA-C
• Widodo & Lee DDS a Professional Dental Corp
• Adam Gregory Wiggins
• Wathmi Sajika Wijesinghe, DPM
• Wilbert T Tsai MD Inc
• Asili Maisha Wilbourn, LVN
• Paulette Wiley

• General Practice Dentistry in Pomona, CA
• Providers in Pomona, 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 Apr 25, 2022; 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.