Basic Information
| Provider Information | |||||||||
| NPI: | 1427238534 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WATANABE SHADOW MOUNTAIN DENTAL GROUP, PROFESSIONAL CORPORATION | ||||||||
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| OtherOrganizationName: | SHADOW MOUNTAIN DENTAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2860 MICHELLE | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926061009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145083600 | ||||||||
| FaxNumber: | 7143682092 | ||||||||
| Practice Location | |||||||||
| Address1: | 6525 N DECATUR BLVD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025771941 | ||||||||
| FaxNumber: | 7023957813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2007 | ||||||||
| LastUpdateDate: | 11/07/2007 | ||||||||
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| AuthorizedOfficialLastName: | WATANABE | ||||||||
| AuthorizedOfficialFirstName: | LYNDA | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 7025771941 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.