Provider Demographics
NPI:1831561836
Name:TABATA, DAVID (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:TABATA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1413 FOOTHILL BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-3418
Mailing Address - Country:US
Mailing Address - Phone:909-596-1831
Mailing Address - Fax:909-593-4722
Practice Address - Street 1:1413 FOOTHILL BLVD STE B
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-3418
Practice Address - Country:US
Practice Address - Phone:909-596-1831
Practice Address - Fax:909-593-4722
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-29
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA265421223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6667470001Medicare NSC