MEDICARE: BERT K. FUNATSU D.D.S.

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	1223G0001X	General Practice Dentistry	17682	CA

General Provider Information

NPI Number	:	1245332097
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BERT K. FUNATSU D.D.S.

Provider Business Mailing Address
First Line	:	301 S FAIR OAKS AVE
Second Line	:	SUITE 205
City	:	PASADENA
State	:	CA
Zip	:	91105-2561
Country	:	US
Telephone Number	:	626-796-8904
Fax Number	:	626-796-8998

Provider Business Practice Location Address
First Line	:	301 S FAIR OAKS AVE
Second Line	:	SUITE 205
City	:	PASADENA
State	:	CA
Zip	:	91105-2561
Country	:	US
Telephone Number	:	626-796-8904
Fax Number	:	626-796-8998

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/02/2006
Last Update Date	:	07/08/2007

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