Provider Demographics
NPI:1356760169
Name:KITAMURA, DAI
Entity type:Individual
Prefix:
First Name:DAI
Middle Name:
Last Name:KITAMURA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18229 DUSK STREET
Mailing Address - Street 2:
Mailing Address - City:ROWLAND HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91748
Mailing Address - Country:US
Mailing Address - Phone:626-991-1121
Mailing Address - Fax:
Practice Address - Street 1:1300 POTRERO GRANDE DRIVE #C
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-2254
Practice Address - Country:US
Practice Address - Phone:626-288-1139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-09
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62911122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist