Provider Demographics
NPI:1265717391
Name:TANAKA, MAMORU (DDS, FACP)
Entity type:Individual
Prefix:
First Name:MAMORU
Middle Name:
Last Name:TANAKA
Suffix:
Gender:M
Credentials:DDS, FACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8008 FROST ST # 800
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4205
Mailing Address - Country:US
Mailing Address - Phone:617-459-9491
Mailing Address - Fax:
Practice Address - Street 1:8008 FROST ST # 800
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4205
Practice Address - Country:US
Practice Address - Phone:617-459-9491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-20
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1015171223P0700X
TX315031223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics