=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619069929
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TANAKA DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 212 CHURCH AVE SUITE A
-----------------------------------------------------
City | CHULA VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91910-2703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-420-8696
-----------------------------------------------------
Fax | 619-420-6915
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 212 CHURCH AVE SUITE A
-----------------------------------------------------
City | CHULA VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91910-2703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-420-8696
-----------------------------------------------------
Fax | 619-420-6915
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KATHERINE M TANAKA
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 619-420-8696
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 40575
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 39210
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------