Healthcare Provider Details

I. General information

NPI: 1730489014
Provider Name (Legal Business Name): THEODORE A TANABE DDS A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2010
Last Update Date: 12/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13203 HADLEY STREET SUITE 101
WHITTIER CA
90601
US

IV. Provider business mailing address

13203 HADLEY STREET SUITE 101
WHITTIER CA
90601
US

V. Phone/Fax

Practice location:
  • Phone: 562-698-0387
  • Fax: 562-696-7677
Mailing address:
  • Phone: 562-698-0387
  • Fax: 562-896-7677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number39716
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number39716
License Number StateCA

VIII. Authorized Official

Name: DR. THEODORE A TANABE
Title or Position: PRESIDENT
Credential: DDS
Phone: 562-698-0387