Provider Demographics
NPI:1497029268
Name:TAKEZAWA, HIDEMI (DDS)
Entity Type:Individual
Prefix:
First Name:HIDEMI
Middle Name:
Last Name:TAKEZAWA
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 1:481 8TH AVE
Mailing Address - Street 2:SUITE 725
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-1809
Mailing Address - Country:US
Mailing Address - Phone:212-967-0817
Mailing Address - Fax:212-967-0817
Practice Address - Street 1:481 8TH AVE
Practice Address - Street 2:SUITE 725
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-1809
Practice Address - Country:US
Practice Address - Phone:212-967-0817
Practice Address - Fax:212-967-0817
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-26
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0472191223G0001X
NJ22DI02521300122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist