Healthcare Provider Details

I. General information

NPI: 1528786795
Provider Name (Legal Business Name): JUSTIN SHORYU OGAWA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2022
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 S OLIVE ST
LOS ANGELES CA
90015-3023
US

IV. Provider business mailing address

23295 COFFEE BERRY CIR
CORONA CA
92883-8134
US

V. Phone/Fax

Practice location:
  • Phone: 213-747-5542
  • Fax:
Mailing address:
  • Phone: 678-670-3533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number107770
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: