Provider Demographics
NPI:1063607851
Name:AMY IWATA DDS INC
Entity type:Organization
Organization Name:AMY IWATA DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:IWATA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-293-6188
Mailing Address - Street 1:3756 SANTA ROSALIA DR
Mailing Address - Street 2:STE 504
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-3606
Mailing Address - Country:US
Mailing Address - Phone:323-293-6188
Mailing Address - Fax:
Practice Address - Street 1:3756 SANTA ROSALIA DR
Practice Address - Street 2:STE 504
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-3606
Practice Address - Country:US
Practice Address - Phone:323-293-6188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27151122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB 27151OtherDENTICAL