Healthcare Provider Details

I. General information

NPI: 1689892242
Provider Name (Legal Business Name): CLAUDIO ENRIQUE IWAMOTO D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 03/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14055 VERONA LN APT#15210
CENTREVILLE VA
20120-6350
US

IV. Provider business mailing address

19490 SANDRIDGE WAY SUITE 270
LEESBURG VA
20176-3465
US

V. Phone/Fax

Practice location:
  • Phone: 410-599-0254
  • Fax:
Mailing address:
  • Phone: 703-858-3838
  • Fax: 703-858-5338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number12701
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number0401410768
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: