Provider Demographics
NPI:1063620219
Name:NAKAMURA, KEN (DDS)
Entity type:Individual
Prefix:DR
First Name:KEN
Middle Name:
Last Name:NAKAMURA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S SAN PEDRO ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012-3809
Mailing Address - Country:US
Mailing Address - Phone:213-620-9236
Mailing Address - Fax:213-625-1499
Practice Address - Street 1:200 S SAN PEDRO ST
Practice Address - Street 2:SUITE 401
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-3809
Practice Address - Country:US
Practice Address - Phone:213-620-9236
Practice Address - Fax:213-625-1499
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA293951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice