Provider Demographics
NPI:1467582577
Name:IKEDA, KENTARO (DDS)
Entity Type:Individual
Prefix:
First Name:KENTARO
Middle Name:
Last Name:IKEDA
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 1:13065 E 17TH AVE
Mailing Address - Street 2:MAIL STOP F844
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80045-2532
Mailing Address - Country:US
Mailing Address - Phone:303-724-9584
Mailing Address - Fax:
Practice Address - Street 1:13065 E 17TH AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-2532
Practice Address - Country:US
Practice Address - Phone:303-724-5505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC150533122300000X
COAD.0000515122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO38820064Medicaid