Healthcare Provider Details

I. General information

NPI: 1295831097
Provider Name (Legal Business Name): BLAINE ISAMU HONDA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 HEARST AVE
BERKELEY CA
94709-2130
US

IV. Provider business mailing address

2020 HEARST AVE
BERKELEY CA
94709-2130
US

V. Phone/Fax

Practice location:
  • Phone: 510-841-0662
  • Fax: 510-841-0917
Mailing address:
  • Phone: 510-841-0662
  • Fax: 510-841-0917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number034454
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: