Provider Demographics
NPI:1104193473
Name:PAUL K. TAKEMOTO, D.D.S., PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:PAUL K. TAKEMOTO, D.D.S., PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:K
Authorized Official - Last Name:TAKEMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:805-553-1980
Mailing Address - Street 1:144 W LOS ANGELES AVE
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-1898
Mailing Address - Country:US
Mailing Address - Phone:805-553-1980
Mailing Address - Fax:805-553-1981
Practice Address - Street 1:144 W LOS ANGELES AVE
Practice Address - Street 2:
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021-1898
Practice Address - Country:US
Practice Address - Phone:805-553-1980
Practice Address - Fax:805-553-1981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35455122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty