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Organization
SULAEMAN PROFESSIONAL DENTAL, INC.
Active
Organization
SULAEMAN PROFESSIONAL DENTAL, INC.
Active
Other names
WIJAYA SULAEMAN, D.D.S.
Organization subpart
No
Provider details
NPI number
Authorized official
DR. AUDREY INDHIRA SULAEMAN D.D.S (DENTIST)
(909) 889-9591
Entity
Organization
Contact information
Practice address
25054 BASE LINE ST, SAN BERNARDINO, CA 92410-4026
(909) 889-9591
(909) 889-8721
Mailing address
25054 BASE LINE ST, SAN BERNARDINO, CA 92410-4026
(909) 889-9591
(909) 889-8721
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
37166
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
D37166
—
CA
05
—
D44254
—
CA
05
—
D48030
—
CA
Enumeration date
03/21/2007
Last updated
08/22/2020
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