Provider Demographics
NPI:1053536953
Name:TANAKA, RAYMUND M (DDS)
Entity type:Individual
Prefix:
First Name:RAYMUND
Middle Name:M
Last Name:TANAKA
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 1:18301 N 79TH AVE
Mailing Address - Street 2:F160
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6045
Mailing Address - Country:US
Mailing Address - Phone:623-878-2600
Mailing Address - Fax:623-878-4730
Practice Address - Street 1:18301 N 79TH AVE
Practice Address - Street 2:F160
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6045
Practice Address - Country:US
Practice Address - Phone:623-878-2600
Practice Address - Fax:623-878-4730
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice