Healthcare Provider Details

I. General information

NPI: 1467867374
Provider Name (Legal Business Name): IAN MICHIO IWANE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2014
Last Update Date: 07/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10102 SAN PABLO AVE NONE
EL CERRITO CA
94530-3510
US

IV. Provider business mailing address

1536 BLAKE ST NONE
BERKELEY CA
94703-1806
US

V. Phone/Fax

Practice location:
  • Phone: 510-559-9000
  • Fax:
Mailing address:
  • Phone: 415-845-0217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number52870
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: