Provider Demographics
NPI:1538235635
Name:JUDO, TERESITA JAHJA (DDS)
Entity type:Individual
Prefix:MRS
First Name:TERESITA
Middle Name:JAHJA
Last Name:JUDO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:TERESITA
Other - Middle Name:
Other - Last Name:JAHJA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1087 NORTH PARK AVENUE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-3026
Mailing Address - Country:US
Mailing Address - Phone:909-629-0201
Mailing Address - Fax:
Practice Address - Street 1:1087 NORTH PARK AVENUE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-3026
Practice Address - Country:US
Practice Address - Phone:909-629-0201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36942122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD36942Medicaid