Healthcare Provider Details

I. General information

NPI: 1124568175
Provider Name (Legal Business Name): BRENT TAKASHI HONDA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2017
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2829 S GRAND AVE
LOS ANGELES CA
90007-3304
US

IV. Provider business mailing address

1200 N STATE ST CLINIC TOWER, SUITE A7D
LOS ANGELES CA
90033-1029
US

V. Phone/Fax

Practice location:
  • Phone: 213-669-7000
  • Fax:
Mailing address:
  • Phone: 808-741-9913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDDS103380
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: