Provider Demographics
NPI:1922159466
Name:TANAKA, WAYNE K (DDS)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:K
Last Name:TANAKA
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 1:11092 UNIVERSITY CT RM 3306
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92350-0001
Mailing Address - Country:US
Mailing Address - Phone:909-558-4671
Mailing Address - Fax:909-558-0285
Practice Address - Street 1:11092 UNIVERSITY CT RM 3306
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-0001
Practice Address - Country:US
Practice Address - Phone:909-558-4671
Practice Address - Fax:909-558-0285
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA512011223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0079700Medicaid
CA00SP18300Medicaid
CA00SP18300Medicaid
CAGR0079700Medicaid