=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710744404
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RODNEY K. ITO DDS, MS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/29/2024
-----------------------------------------------------
Last Update Date | 02/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 946 W WINTON AVE
-----------------------------------------------------
City | HAYWARD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94545-1521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-785-1441
-----------------------------------------------------
Fax | 510-785-1468
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 404 HEATHER RIDGE CT
-----------------------------------------------------
City | SAN RAMON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94582-5130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-216-5634
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 33472
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------