=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740784982
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IRINE SIMS-KOMATSU DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2018
-----------------------------------------------------
Last Update Date | 03/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11980 SAN VICENTE BLVD STE 906
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90049-6607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-207-5900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11980 SAN VICENTE BLVD STE 906
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90049-6607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-207-5900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 42230
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------