Healthcare Provider Details

I. General information

NPI: 1437133063
Provider Name (Legal Business Name): KEITH C. HARADA, D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 W BEVERLY BLVD SUITE D
MONTEBELLO CA
90640-3971
US

IV. Provider business mailing address

1717 W BEVERLY BLVD SUITE D
MONTEBELLO CA
90640-3971
US

V. Phone/Fax

Practice location:
  • Phone: 323-726-1544
  • Fax: 323-726-3091
Mailing address:
  • Phone: 323-726-1544
  • Fax: 323-726-3091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number19430
License Number StateCA

VIII. Authorized Official

Name: DR. KEITH CHITOSE HARADA
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 323-726-1544