Provider Demographics
NPI:1053391193
Name:NAKAYAMA, WAYNE TETSUO (DDS)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:TETSUO
Last Name:NAKAYAMA
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 1:4514 S CENTINELA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-6206
Mailing Address - Country:US
Mailing Address - Phone:310-397-6719
Mailing Address - Fax:310-397-2069
Practice Address - Street 1:4514 S CENTINELA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-6206
Practice Address - Country:US
Practice Address - Phone:310-397-6719
Practice Address - Fax:310-397-2069
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA248411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice