=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437133063
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEITH C. HARADA, D.D.S., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1717 W BEVERLY BLVD SUITE D
-----------------------------------------------------
City | MONTEBELLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90640-3971
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-726-1544
-----------------------------------------------------
Fax | 323-726-3091
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1717 W BEVERLY BLVD SUITE D
-----------------------------------------------------
City | MONTEBELLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90640-3971
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-726-1544
-----------------------------------------------------
Fax | 323-726-3091
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KEITH CHITOSE HARADA
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 323-726-1544
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 19430
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------