Basic Information
Provider Information | |||||||||
NPI: | 1831298256 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WATANABE DENTAL CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MURRIETA DENTAL GROUP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2860 MICHELLE | ||||||||
Address2: | 2ND FLOOR | ||||||||
City: | IRVINE | ||||||||
State: | CA | ||||||||
PostalCode: | 926061009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7145083600 | ||||||||
FaxNumber: | 7143682092 | ||||||||
Practice Location | |||||||||
Address1: | 40770 CALIFORNIA OAKS RD | ||||||||
Address2: |   | ||||||||
City: | MURRIETA | ||||||||
State: | CA | ||||||||
PostalCode: | 925625727 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9516773078 | ||||||||
FaxNumber: | 9516000498 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2006 | ||||||||
LastUpdateDate: | 11/12/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WATANABE | ||||||||
AuthorizedOfficialFirstName: | BRYAN | ||||||||
AuthorizedOfficialMiddleName: | K | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER DDS | ||||||||
AuthorizedOfficialTelephone: | 9516773078 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DDS | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.