MEDICARE: IWAMOTO ENTERPRISES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	292200000X	Dental Laboratory	FAC00046448	CA

General Provider Information

NPI Number	:	1023408580
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IWAMOTO ENTERPRISES, INC.

Provider Business Mailing Address
First Line	:	5451 LAUREL CANYON BLVD
Second Line	:	SUITE 202
City	:	VALLEY VILLAGE
State	:	CA
Zip	:	91607-2180
Country	:	US
Telephone Number	:	818-506-6861
Fax Number	:	818-506-3643

Provider Business Practice Location Address
First Line	:	5451 LAUREL CANYON BLVD
Second Line	:	SUITE 202
City	:	VALLEY VILLAGE
State	:	CA
Zip	:	91607-2180
Country	:	US
Telephone Number	:	818-506-6861
Fax Number	:	818-506-3643

Authorized Official
Title or Position	:	CEO/PRESIDENT
Name	:	MR. ERIC TAKEO IWAMOTO
Credential	:
Telephone Number	:	818-506-6861

Provider Enumeration Date	:	02/04/2015
Last Update Date	:	02/04/2015

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