Provider Demographics
NPI:1396895751
Name:TAYENAKA, TED E (DDS)
Entity type:Individual
Prefix:DR
First Name:TED
Middle Name:E
Last Name:TAYENAKA
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 1:3532 HOWARD AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3681
Mailing Address - Country:US
Mailing Address - Phone:562-596-0100
Mailing Address - Fax:562-596-0155
Practice Address - Street 1:3532 HOWARD AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3681
Practice Address - Country:US
Practice Address - Phone:562-596-0100
Practice Address - Fax:562-596-0155
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA379361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB37936-01Medicaid