Individual
DR. ANDRE WIDODO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
2112 S GAREY AVE STE A, POMONA, CA 91766-5600
(909) 590-5600
(909) 590-5606
Mailing address
2112 S GAREY AVE STE A, POMONA, CA 91766-5600
(909) 590-5600
(909) 590-5606
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
46152
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1184972135
DENTIST
CA
Enumeration date
02/20/2007
Last updated
04/25/2022
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