Provider Demographics
NPI:1780056135
Name:BRYAN WATANABE DDS LIBERTY DENTAL GROUP PC
Entity type:Organization
Organization Name:BRYAN WATANABE DDS LIBERTY DENTAL GROUP PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:WATANABE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-728-2979
Mailing Address - Street 1:17000 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5626
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:8291 N BOOTH AVENUE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64158
Practice Address - Country:US
Practice Address - Phone:816-728-2979
Practice Address - Fax:816-415-3286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty