Provider Demographics
NPI:1962817882
Name:IAN IWANE DDS
Entity Type:Organization
Organization Name:IAN IWANE DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IAN
Authorized Official - Middle Name:MICHIO
Authorized Official - Last Name:IWANE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:415-845-0217
Mailing Address - Street 1:1536 BLAKE ST
Mailing Address - Street 2:NONE
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-1806
Mailing Address - Country:US
Mailing Address - Phone:415-845-0217
Mailing Address - Fax:
Practice Address - Street 1:1536 BLAKE ST
Practice Address - Street 2:NONE
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94703-1806
Practice Address - Country:US
Practice Address - Phone:415-845-0217
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-30
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52870122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty