=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730489014
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THEODORE A TANABE DDS A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2010
-----------------------------------------------------
Last Update Date | 12/26/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13203 HADLEY STREET SUITE 101
-----------------------------------------------------
City | WHITTIER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-698-0387
-----------------------------------------------------
Fax | 562-696-7677
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13203 HADLEY STREET SUITE 101
-----------------------------------------------------
City | WHITTIER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-698-0387
-----------------------------------------------------
Fax | 562-896-7677
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. THEODORE A TANABE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 562-698-0387
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
-----------------------------------------------------
License Number | 39716
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 39716
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------