Provider Demographics
NPI:1992911408
Name:THE, POPPY WIDYASTUTI (DDS)
Entity type:Individual
Prefix:DR
First Name:POPPY
Middle Name:WIDYASTUTI
Last Name:THE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8902 WOODMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ARLETA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-6401
Mailing Address - Country:US
Mailing Address - Phone:818-830-7133
Mailing Address - Fax:818-830-7280
Practice Address - Street 1:20800 SHERMAN WAY
Practice Address - Street 2:
Practice Address - City:WINNETKA
Practice Address - State:CA
Practice Address - Zip Code:91306-2707
Practice Address - Country:US
Practice Address - Phone:818-883-2273
Practice Address - Fax:818-896-1074
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA262891223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1083624423Medicaid
CA1538130893Medicaid