MEDICARE: BRYAN WATANABE DDS, WHITE OAKS DENTAL GROUP, PC

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	122300000X	Dentist

General Provider Information

NPI Number	:	1457872962
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRYAN WATANABE DDS, WHITE OAKS DENTAL GROUP, PC

Provider Business Mailing Address
First Line	:	17000 RED HILL AVE
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92614-5626
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1125 S 7 HWY
Second Line	:
City	:	BLUE SPRINGS
State	:	MO
Zip	:	64014-3204
Country	:	US
Telephone Number	:	816-622-1029
Fax Number	:

Authorized Official
Title or Position	:	DDS/OWNER
Name	:	JENNIFER CRUMBAUGH
Credential	:
Telephone Number	:	816-622-1029

Provider Enumeration Date	:	07/06/2017
Last Update Date	:	07/06/2017

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