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General NPI Number Information
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NPI Number | 1528786795
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Entity Type | Individual
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Provider Name | JUSTIN SHORYU OGAWA DMD
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Gender | Male
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Dates
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Enumeration Date | 08/15/2022
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Last Update Date | 08/24/2022
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Provider Practice Location Address
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Address Line | 1530 S OLIVE ST
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City | LOS ANGELES
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State | CA
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Zip | 90015-3023
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Country | US
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Telephone | 213-747-5542
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Fax |
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Provider Business Mailing Address
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Address Line | 23295 COFFEE BERRY CIR
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City | CORONA
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State | CA
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Zip | 92883-8134
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Country | US
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Telephone | 678-670-3533
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 107770
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License Number State | CA
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