Healthcare Provider Details

I. General information

NPI: 1952536963
Provider Name (Legal Business Name): MIKAKO KUGA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 08/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11201 CALIFORNIA ST. SUIT D
REDLANDS CA
92373
US

IV. Provider business mailing address

11201 CALIFORNIA ST. SUIT D
REDLANDS CA
92373
US

V. Phone/Fax

Practice location:
  • Phone: 909-307-6453
  • Fax: 909-307-6089
Mailing address:
  • Phone: 909-307-6453
  • Fax: 909-307-6089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number41444
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: