NPI: 1184972135 · CHINO, CA 91710 · Dental Clinic/Center · NPI assigned 08/23/2012
| Authorized Official | WIDODO, ANDRE (OWNER) |
| NPI Enumeration Date | 08/23/2012 |
Other providers sharing the same authorized official: WIDODO, ANDRE
| Provider | City | State | Total Paid |
|---|---|---|---|
| WIDODO & LEE DDS A PROFESSIONAL DENTAL CORP | POMONA | CA | $609K |
| ANDRE WIDODO DDS A PROFESSIONAL CORPORATION | EL MONTE | CA | $157K |
| Year | Claims | Total Paid |
|---|---|---|
| 2018 | 5,067 | $57K |
| 2019 | 4,290 | $50K |
| 2020 | 2,462 | $27K |
| 2021 | 2,849 | $27K |
| 2022 | 2,291 | $32K |
| 2023 | 1,751 | $18K |
| 2024 | 2,090 | $23K |
| Code | Description | Claims | Bene. Records | Total Paid |
|---|---|---|---|---|
| D0230 | Intraoral - periapical each additional radiographic image | 13,613 | 2,582 | $56K |
| D1120 | Prophylaxis - child | 1,174 | 1,169 | $39K |
| D0120 | Periodic oral evaluation - established patient | 884 | 879 | $38K |
| D0272 | Bitewings - two radiographic images | 2,251 | 2,231 | $26K |
| D1208 | Topical application of fluoride, excluding varnish | 2,125 | 2,112 | $25K |
| D1110 | Prophylaxis - adult | 243 | 237 | $18K |
| D0150 | Comprehensive oral evaluation - new or established patient | 288 | 285 | $17K |
| D2150 | Silver amalgam - two surfaces, primary or permanent | 194 | 108 | $13K |
| D9230 | Inhalation of nitrous oxide / analgesia, anxiolysis | 15 | 12 | $490.00 |
| D0220 | Intraoral - periapical first radiographic image | 13 | 13 | $156.00 |