MEDICARE: WATANABE TOWN CENTER DENTAL GROUP, PROFESSIONAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1104954833
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WATANABE TOWN CENTER DENTAL GROUP, PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	2860 MICHELLE DRIVE
Second Line	:	2ND FLOOR
City	:	IRVINE
State	:	CA
Zip	:	92606-1009
Country	:	US
Telephone Number	:	714-845-8890
Fax Number	:	949-474-1495

Provider Business Practice Location Address
First Line	:	7125 N DURANGO DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-4466
Country	:	US
Telephone Number	:	702-658-2311
Fax Number	:	702-658-8811

Authorized Official
Title or Position	:	OWNER DOCTOR
Name	:	DR. LYNDA WATANABE
Credential	:
Telephone Number	:	702-658-2311

Provider Enumeration Date	:	03/02/2007
Last Update Date	:	08/02/2013

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