Provider Demographics
NPI:1265745384
Name:KOMABAYASHI, TAKASHI (DDS, MDS, PHD)
Entity type:Individual
Prefix:DR
First Name:TAKASHI
Middle Name:
Last Name:KOMABAYASHI
Suffix:
Gender:M
Credentials:DDS, MDS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2656
Mailing Address - Country:US
Mailing Address - Phone:207-221-4721
Mailing Address - Fax:
Practice Address - Street 1:716 STEVENS AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2656
Practice Address - Country:US
Practice Address - Phone:207-221-4721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-18
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME44381223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics