Provider Demographics
NPI:1225442395
Name:KOUICHI ITOH DDS INC.
Entity Type:Organization
Organization Name:KOUICHI ITOH DDS INC.
Other - Org Name:THE LOFT DENTAL STUDIO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KOUICHI
Authorized Official - Middle Name:CLIFF
Authorized Official - Last Name:ITOH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-549-7030
Mailing Address - Street 1:3151 AIRWAY AVE
Mailing Address - Street 2:STE. F-103
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-4607
Mailing Address - Country:US
Mailing Address - Phone:714-549-7030
Mailing Address - Fax:714-464-4538
Practice Address - Street 1:3151 AIRWAY AVE
Practice Address - Street 2:STE. F-103
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4607
Practice Address - Country:US
Practice Address - Phone:714-549-7030
Practice Address - Fax:714-464-4538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39420122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty