Provider Demographics
NPI:1376705129
Name:TAKENAKA, YASUNORI (DDS)
Entity Type:Individual
Prefix:DR
First Name:YASUNORI
Middle Name:
Last Name:TAKENAKA
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:PO BOX 8230
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GUAM
Mailing Address - Zip Code:96931
Mailing Address - Country:UM
Mailing Address - Phone:671-649-7851
Mailing Address - Fax:671-649-7853
Practice Address - Street 1:590 S. MARINE CORPS DR. SUITE 104, ITC BLDG
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GUAM
Practice Address - Zip Code:96913
Practice Address - Country:UM
Practice Address - Phone:671-649-7851
Practice Address - Fax:671-649-7853
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-01
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GU994122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GU994-969133555OtherDELTA DENTAL
GU1651883OtherUNITED CONCORDIA