| Wijaya Sulaeman, D.d.s. | |
|
25054 Base Line St San Bernardino CA 92410-4026 | |
| (909) 889-9591 | |
| (909) 889-8721 |
| Full Name | Wijaya Sulaeman, D.d.s. |
|---|---|
| Speciality | Dentist - General Practice |
| Location | 25054 Base Line St, San Bernardino, California |
| Authorized Official Name and Position | Audrey Indhira Sulaeman (DENTIST) |
| Authorized Official Contact | 9098899591 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Wijaya Sulaeman, D.d.s. 25054 Base Line St San Bernardino CA 92410-4026 Ph: (909) 889-9591 | Wijaya Sulaeman, D.d.s. 25054 Base Line St San Bernardino CA 92410-4026 Ph: (909) 889-9591 |
| NPI Number | 1063537538 |
|---|---|
| Provider Enumeration Date | 03/21/2007 |
| Last Update Date | 08/22/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1063537538 | NPI | - | NPPES |
| D37166 | Medicaid | CA | |
| D44254 | Medicaid | CA | |
| D48030 | Medicaid | CA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | 37166 (California) | Primary |
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