Healthcare Provider Details

I. General information

NPI: 1962693283
Provider Name (Legal Business Name): MARIO EA WA TAI D.M.D., D.M.SC.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 10/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 BARRANCA PKWY SUITE 220
IRVINE CA
92604-7706
US

IV. Provider business mailing address

2803 LADRILLO AISLE
IRVINE CA
92606-8819
US

V. Phone/Fax

Practice location:
  • Phone: 646-708-3709
  • Fax: 949-861-9889
Mailing address:
  • Phone: 646-708-3709
  • Fax: 949-861-9889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number53735
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: