Healthcare Provider Details

I. General information

NPI: 1497431175
Provider Name (Legal Business Name): ANDREW IKAZAKI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2023
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11340 W OLYMPIC BLVD STE 360
LOS ANGELES CA
90064-1624
US

IV. Provider business mailing address

11340 W OLYMPIC BLVD STE 360
LOS ANGELES CA
90064-1624
US

V. Phone/Fax

Practice location:
  • Phone: 310-473-2727
  • Fax:
Mailing address:
  • Phone: 310-473-2727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number105743
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: