Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 64110 | CA |
N | 122300000X | Dentist | DE60264061 | WA |
NPI | 1003219064 |
---|---|
Provider Name | Dr. Tomoko Wada |
First Address | Los Angeles, CA 90089-0641 |
Second Address | Los Angeles, CA 90089-0058 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/10/2014 |
Last Update Date | 20/07/2015 |