Healthcare Provider Details

I. General information

NPI: 1972695864
Provider Name (Legal Business Name): GARY NORIAKI KITAZAWA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 WILSHIRE BLVD SUITE 404
LOS ANGELES CA
90017-3901
US

IV. Provider business mailing address

1127 WILSHIRE BLVD. SUITE 404
LOS ANGELES CA
90017-3905
US

V. Phone/Fax

Practice location:
  • Phone: 213-481-1127
  • Fax: 213-481-1510
Mailing address:
  • Phone: 213-481-1127
  • Fax: 213-481-1510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number23000
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: