Healthcare Provider Details

I. General information

NPI: 1740389162
Provider Name (Legal Business Name): LEE WATANABE AND NOSTI DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 06/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 W FLORIDA AVE
HEMET CA
92545-5279
US

IV. Provider business mailing address

2860 MICHELLE DRIVE 2ND FLOOR
IRVINE CA
92606-1009
US

V. Phone/Fax

Practice location:
  • Phone: 951-658-9980
  • Fax: 951-929-0541
Mailing address:
  • Phone: 714-508-3600
  • Fax: 714-368-2092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number40130
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number37772
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number53124
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number51049
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number49975
License Number StateCA

VIII. Authorized Official

Name: DR. BRYAN K WATANABE
Title or Position: OWNER DDS
Credential: DDS
Phone: 951-658-9980