Provider Demographics
NPI:1659591782
Name:WATANABE, KEITH TAKASHI (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:TAKASHI
Last Name:WATANABE
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 1:420 EAST THIRD STREET SUITE 807
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-1647
Mailing Address - Country:US
Mailing Address - Phone:213-620-9906
Mailing Address - Fax:
Practice Address - Street 1:420 EAST THIRD STREET SUITE 807
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-1647
Practice Address - Country:US
Practice Address - Phone:213-620-9906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21963122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist