Provider Demographics
NPI:1457445231
Name:DIANA DO-YABUT AND BRYAN WATANABE DENTAL CORPORATION
Entity Type:Organization
Organization Name:DIANA DO-YABUT AND BRYAN WATANABE DENTAL CORPORATION
Other - Org Name:CLINTON KEITH DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:WATANABE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:951-304-9700
Mailing Address - Street 1:2860 MICHELLE DRIVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-1009
Mailing Address - Country:US
Mailing Address - Phone:714-368-2077
Mailing Address - Fax:714-368-2092
Practice Address - Street 1:23905 CLINTON KEITH RD
Practice Address - Street 2:STE. 108
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-7897
Practice Address - Country:US
Practice Address - Phone:951-304-9700
Practice Address - Fax:951-304-9711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA401301223G0001X
CA497841223G0001X
CA377721223P0300X
CA500801223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty