Provider Demographics
NPI:1497431175
Name:IKAZAKI, ANDREW (DDS)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:IKAZAKI
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 1:11340 W OLYMPIC BLVD STE 360
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-1624
Mailing Address - Country:US
Mailing Address - Phone:310-473-2727
Mailing Address - Fax:
Practice Address - Street 1:11340 W OLYMPIC BLVD STE 360
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1624
Practice Address - Country:US
Practice Address - Phone:310-473-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1057431223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty