Provider Demographics
NPI:1932218724
Name:WADA, ERIC MINORU (DDS)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:MINORU
Last Name:WADA
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 1:764 W LANCASTER BLVD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-3130
Mailing Address - Country:US
Mailing Address - Phone:661-945-0863
Mailing Address - Fax:661-945-0523
Practice Address - Street 1:764 W LANCASTER BLVD
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3130
Practice Address - Country:US
Practice Address - Phone:661-945-0863
Practice Address - Fax:661-945-0523
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29119122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist