Provider Demographics
NPI:1689844011
Name:TAKEHANA, SHIGERU (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHIGERU
Middle Name:
Last Name:TAKEHANA
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 1:1717 W BEVERLY BLVD
Mailing Address - Street 2:SUITE # C
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-3971
Mailing Address - Country:US
Mailing Address - Phone:323-724-9326
Mailing Address - Fax:323-724-3477
Practice Address - Street 1:1717 W BEVERLY BLVD
Practice Address - Street 2:SUITE # C
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-3971
Practice Address - Country:US
Practice Address - Phone:323-724-9326
Practice Address - Fax:323-724-3477
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-29
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA212111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice