Provider Demographics
NPI:1417151713
Name:NAKAGAWA, GRANT R (DDS)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:R
Last Name:NAKAGAWA
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 1:10231 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-6420
Mailing Address - Country:US
Mailing Address - Phone:310-551-1902
Mailing Address - Fax:
Practice Address - Street 1:10231 SANTA MONICA BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-6420
Practice Address - Country:US
Practice Address - Phone:310-551-1902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31340122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist