Provider Demographics
NPI:1467597377
Name:IWATA, AMY (DDS)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:
Last Name:IWATA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3756 SANTA ROSALIA DRIVE
Mailing Address - Street 2:SUITE 504
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-3656
Mailing Address - Country:US
Mailing Address - Phone:323-293-2600
Mailing Address - Fax:
Practice Address - Street 1:3756 SANTA ROSALIA DRIVE
Practice Address - Street 2:SUITE 504
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-3656
Practice Address - Country:US
Practice Address - Phone:323-293-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA271511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice