Larasati Kianti Putri, drg., Sp.KGASIP : 021411131048

Jam Praktik : Senin-Jumat, pukul 08.00 – 14.00 WIBNo. Telepon : 0817373023

Alamat : Jl. Raya Gubeng No.70, Gubeng, Kota SBY, Jawa Timur 60281

Siloam Internasional Hospital

Surabaya, ...............................R/

Pro : ............................................................................Umur : ................................ BB : ...............................Alamat : ..................................................................................

Larasati Kianti Putri, drg., Sp.KGASIP : 021411131048

Jam Praktik : Senin-Jumat, pukul 08.00 – 14.00 WIBNo. Telepon : 0817373023

Alamat : Jl. Raya Gubeng No.70, Gubeng, Kota SBY, Jawa Timur 60281

Siloam International Hospital

Surabaya, .........................

R/

Pro : ............................................................................Umur : ................................ BB : ...............................Alamat : ..................................................................................