Provider Demographics
NPI:1164588737
Name:KODAMA, KEITH S (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:S
Last Name:KODAMA
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 1:14213 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-5835
Mailing Address - Country:US
Mailing Address - Phone:714-832-8220
Mailing Address - Fax:
Practice Address - Street 1:14213 RED HILL AVE
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-5835
Practice Address - Country:US
Practice Address - Phone:714-832-8220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32646122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist