Provider Demographics
NPI:1427238534
Name:WATANABE SHADOW MOUNTAIN DENTAL GROUP, PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:WATANABE SHADOW MOUNTAIN DENTAL GROUP, PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:C
Authorized Official - Last Name:WATANABE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:702-577-1941
Mailing Address - Street 1:2860 MICHELLE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-1009
Mailing Address - Country:US
Mailing Address - Phone:714-508-3600
Mailing Address - Fax:714-368-2092
Practice Address - Street 1:6525 N DECATUR BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89131
Practice Address - Country:US
Practice Address - Phone:702-577-1941
Practice Address - Fax:702-395-7813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty