Healthcare Provider Details

I. General information

NPI: 1467582577
Provider Name (Legal Business Name): KENTARO IKEDA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 PARKMAN ST
BOSTON MA
02114-3117
US

IV. Provider business mailing address

13065 E 17TH AVE MAIL STOP F844
AURORA CO
80045-2532
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-7240
  • Fax:
Mailing address:
  • Phone: 303-724-9584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDF11935
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number150533
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: