Provider Demographics
NPI:1063537538
Name:SULAEMAN PROFESSIONAL DENTAL, INC.
Entity type:Organization
Organization Name:SULAEMAN PROFESSIONAL DENTAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:INDHIRA
Authorized Official - Last Name:SULAEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-889-9591
Mailing Address - Street 1:25054 BASE LINE ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-4026
Mailing Address - Country:US
Mailing Address - Phone:909-889-9591
Mailing Address - Fax:909-889-8721
Practice Address - Street 1:25054 BASE LINE ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-4026
Practice Address - Country:US
Practice Address - Phone:909-889-9591
Practice Address - Fax:909-889-8721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA371661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD37166Medicaid
CAD44254Medicaid
CAD48030Medicaid