Provider Demographics
NPI:1962774414
Name:SHIMOTSU, WARREN KEN (DDS)
Entity type:Individual
Prefix:
First Name:WARREN
Middle Name:KEN
Last Name:SHIMOTSU
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 1:665 S KNICKERBOCKER DR
Mailing Address - Street 2:SUITE # 10
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-1033
Mailing Address - Country:US
Mailing Address - Phone:408-720-0638
Mailing Address - Fax:
Practice Address - Street 1:665 S KNICKERBOCKER DR
Practice Address - Street 2:SUITE # 10
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087-1033
Practice Address - Country:US
Practice Address - Phone:408-720-0638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA 308631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice