Healthcare Provider Details

I. General information

NPI: 1851989883
Provider Name (Legal Business Name): MATTHEW JOHN KOJI MIZONO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2021
Last Update Date: 01/05/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 KAINS AVE
ALBANY CA
94706-1605
US

IV. Provider business mailing address

730 KAINS AVE
ALBANY CA
94706-1605
US

V. Phone/Fax

Practice location:
  • Phone: 510-525-2899
  • Fax:
Mailing address:
  • Phone: 510-525-2899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDDS103335
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: