NPI: 1942603105 · LA VERNE, CA 91750 · General Practice Dentistry · NPI assigned 10/02/2014
| Authorized Official | SUMARDI, KUSUMO (PRESIDENT) |
| NPI Enumeration Date | 10/02/2014 |
| Year | Claims | Total Paid |
|---|---|---|
| 2022 | 183 | $3K |
| 2023 | 90 | $1K |
| Code | Description | Claims | Beneficiaries | Total Paid |
|---|---|---|---|---|
| D0120 | Periodic oral evaluation - established patient | 28 | 28 | $2K |
| D0150 | Comprehensive oral evaluation - new or established patient | 13 | 13 | $858.00 |
| D0230 | Intraoral - periapical each additional radiographic image | 179 | 58 | $724.95 |
| D0274 | Bitewings - four radiographic images | 27 | 27 | $540.00 |
| D1208 | Topical application of fluoride, excluding varnish | 26 | 26 | $413.00 |