Healthcare Provider Details

I. General information

NPI: 1306437967
Provider Name (Legal Business Name): KYOKA MIZUNO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2021
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43000 MIDWAY AVE # 595
SAN DIEGO CA
92140-5692
US

IV. Provider business mailing address

43000 MIDWAY AVE # 595
SAN DIEGO CA
92140-5692
US

V. Phone/Fax

Practice location:
  • Phone: 619-524-4006
  • Fax:
Mailing address:
  • Phone: 619-524-4006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: