Healthcare Provider Details

I. General information

NPI: 1669602694
Provider Name (Legal Business Name): STANLEY H. NAKAMURA D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2009
Last Update Date: 12/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 PROSPECT ST SUITE 5
LA JOLLA CA
92037-4208
US

IV. Provider business mailing address

850 PROSPECT ST SUITE 5
LA JOLLA CA
92037-4208
US

V. Phone/Fax

Practice location:
  • Phone: 858-454-0325
  • Fax: 858-454-5810
Mailing address:
  • Phone: 858-454-0325
  • Fax: 858-454-5810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number30457
License Number StateCA

VIII. Authorized Official

Name: LINH NAKAMURA
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 858-454-0325