=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437633872
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYLLIS K. KAWADA, DDS, MS, A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2018
-----------------------------------------------------
Last Update Date | 09/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 731 N BEACH BLVD STE 120
-----------------------------------------------------
City | LA HABRA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90631-3690
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-226-1636
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 731 N BEACH BLVD STE 120
-----------------------------------------------------
City | LA HABRA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90631-3690
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-690-3750
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. PHYLLIS KAZUMI KAWADA
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 562-690-3750
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------