Healthcare Provider Details

I. General information

NPI: 1609085133
Provider Name (Legal Business Name): CHRISTOPHER A IWATA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 W 21ST ST APT 2
SAN PEDRO CA
90731-5550
US

IV. Provider business mailing address

665 W 21ST ST APT 2
SAN PEDRO CA
90731-5550
US

V. Phone/Fax

Practice location:
  • Phone: 310-832-1440
  • Fax:
Mailing address:
  • Phone: 310-832-1440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number25545
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number469
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE00006955
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDT1354
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: