Damita Dora Wiredja, DDA

Primary specialty

DentistTaxonomy code 122300000X

License

DDS106565 Issued in CA

Practice address

6100 Atlantic Blvd Ste I
Maywood, CA 90270-3184

Phone

(323) 771-7551

Fax

(323) 771-7881

NPI assigned

Dec 14, 2021

Last updated

Jan 5, 2022By the provider in NPPES

Sex

Female

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

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, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Heru Wiredja,DDS,Inc

  • Dentist
  • Maywood, CA
  • NPI 1659783918
  NPD (past)

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

{
    "created_epoch": "1639440000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1641340800000",
    "number": "1740949056",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6100 ATLANTIC BLVD STE I",
            "city": "MAYWOOD",
            "state": "CA",
            "postal_code": "902703184",
            "telephone_number": "323-771-7551",
            "fax_number": "323-771-7881"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6100 ATLANTIC BLVD STE I",
            "city": "MAYWOOD",
            "state": "CA",
            "postal_code": "902703184",
            "telephone_number": "323-771-7551",
            "fax_number": "323-771-7881"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WIREDJA",
        "first_name": "DAMITA",
        "middle_name": "DORA",
        "name_prefix": "Dr.",
        "credential": "DDA",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2021-12-14",
        "last_updated": "2022-01-05",
        "certification_date": "2022-01-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "CA",
            "license": "DDS106565",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PRIVATE",
            "identifier": "DDS106565",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• United Medical Imaging Healthcare, Inc. (United Medical Imaging of Maywood)
• United Medical Radiology Network (United Medical Radiology Network of Maywood)
• Viridiana Elizabeth Vazquez, ASW
• Western Dental Services, Inc.
• Heather Deanna Winther, DDS
• Heru Wiredja, DDS
• Henry C Wong
• James T Wong, DDS
• Malakeh Zahedi, DDS

• Dentist in Maywood, CA
• Providers in Maywood, CA by specialty
• Dentist in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 5, 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.