Provider Demographics
NPI:1831386168
Name:P PUTRASAHAN DDS INC
Entity type:Organization
Organization Name:P PUTRASAHAN DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PERRI
Authorized Official - Middle Name:SOFIAN
Authorized Official - Last Name:PUTRASAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-325-2503
Mailing Address - Street 1:68905 VISTA CHINO
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-4866
Mailing Address - Country:US
Mailing Address - Phone:760-325-2503
Mailing Address - Fax:
Practice Address - Street 1:68905 VISTA CHINO
Practice Address - Street 2:
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-4866
Practice Address - Country:US
Practice Address - Phone:760-325-2503
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA394661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty