Healthcare Provider Details

I. General information

NPI: 1649241092
Provider Name (Legal Business Name): BRETT M NAGATANI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 09/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 W 34TH ST STE 124C
LOS ANGELES CA
90089-0641
US

IV. Provider business mailing address

11551 AMALFI WAY
PORTER RANCH CA
91326-4099
US

V. Phone/Fax

Practice location:
  • Phone: 213-740-1080
  • Fax:
Mailing address:
  • Phone: 323-440-3584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number55266
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number22375
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDT - 2276
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: