=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720692890
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | K ITOH DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2020
-----------------------------------------------------
Last Update Date | 10/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11100 WARNER AVE STE 160
-----------------------------------------------------
City | FOUNTAIN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92708-7510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-799-9945
-----------------------------------------------------
Fax | 657-218-9699
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11100 WARNER AVE STE 160
-----------------------------------------------------
City | FOUNTAIN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92708-7510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-799-9945
-----------------------------------------------------
Fax | 657-218-9699
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. KOUICHI CLIFF ITOH
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 714-799-9945
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------