Provider Demographics
NPI:1588842702
Name:WATANABE DIAMOND DENTAL GROUP, PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:WATANABE DIAMOND 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:702-425-4424
Mailing Address - Street 1:17000 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5626
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:4380 BLUE DIAMOND ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89139
Practice Address - Country:US
Practice Address - Phone:702-425-4424
Practice Address - Fax:702-875-4230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty