Provider Demographics
NPI:1700164530
Name:OKAZAKI, THEODORE RYU (DDS)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:RYU
Last Name:OKAZAKI
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 1:39560 STEVENSON PL STE 219
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-3074
Mailing Address - Country:US
Mailing Address - Phone:510-794-9999
Mailing Address - Fax:510-797-7460
Practice Address - Street 1:39560 STEVENSON PL STE 219
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94539-3074
Practice Address - Country:US
Practice Address - Phone:510-794-9999
Practice Address - Fax:510-797-7460
Is Sole Proprietor?:No
Enumeration Date:2011-07-27
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37717122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist