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PARK AVENUE FAMILY DENTISTRY NPI 1205019858


NPI Information

NPI: 1205019858
Provider Name: PARK AVENUE FAMILY DENTISTRY

Doing Business As: PARK AVENUE FAMILY DENTISTRY

Classification: Dentist - 1223G0001X
Entity Type: Organization

Specialization: General Practice

Address:
1087 N PARK AVE
POMONA, CA
ZIP 91768
Phone: (909) 629-0201
Get Directions

PARK AVENUE FAMILY DENTISTRY is a general practice dentist in Pomona, CA. The provider is a general dentist is the primary dental care provider for patients of all ages. The general dentist is responsible for the diagnosis, treatment, management and overall coordination of services related to patients' oral health needs. PARK AVENUE FAMILY DENTISTRY NPI is 1205019858. The provider is registered as an organization entity type and is a single specialty group.
The provider Is Doing Business As Park Avenue Family Dentistry.

The provider's business location address is:

1087 N PARK AVE
POMONA, CA
ZIP 91768-026
Phone: (909) 629-0201

The provider's authorized official is Soedharsono Judo .
The authorized official title is Owner and has the following contact phone number (909) 629-0201.

The enumeration date for this NPI number is 12/6/2007 and was last updated on 12/6/2007.


Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No.Taxonomy CodeTaxonomy ClasificationTaxonomy SpecializationLicense NumberLicense StatePrimary
11223G0001XDentistGeneral Practice34127CALIFORNIAYes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No.Other Provider IdentifierOther Provider Identifier TypeOther Provider Identifier StateOther Provider Identifier Issuer
1G9044501MEDICAIDCALIFORNIA

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 11/14/2023

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