Basic Information
| Provider Information | |||||||||
| NPI: | 1063815256 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | H. HADIDJAJA, DDS INC. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3122 E FLORENCE AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902555830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235880001 | ||||||||
| FaxNumber: | 9999999999 | ||||||||
| Practice Location | |||||||||
| Address1: | 3122 E FLORENCE AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902555830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235880001 | ||||||||
| FaxNumber: | 9999999999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2014 | ||||||||
| LastUpdateDate: | 10/01/2014 | ||||||||
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| AuthorizedOfficialLastName: | HADIDJAJA | ||||||||
| AuthorizedOfficialFirstName: | HAMI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3235880001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.D.S. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 41834 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.