Healthcare Provider Details

I. General information

NPI: 1528529575
Provider Name (Legal Business Name): ROBB MAKOTO KANEKO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2019
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3465 TORRANCE BLVD STE G
TORRANCE CA
90503-5804
US

IV. Provider business mailing address

4042 W 179TH ST
TORRANCE CA
90504-3733
US

V. Phone/Fax

Practice location:
  • Phone: 310-543-7788
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS105817
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: