Healthcare Provider Details

I. General information

NPI: 1023882149
Provider Name (Legal Business Name): RYAN MIYASAKI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2023
Last Update Date: 11/09/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 OLYMPIC BLVD
WALNUT CREEK CA
94595-1623
US

IV. Provider business mailing address

2225 OLYMPIC BLVD
WALNUT CREEK CA
94595-1623
US

V. Phone/Fax

Practice location:
  • Phone: 925-934-3251
  • Fax: 925-934-2136
Mailing address:
  • Phone: 925-934-3251
  • Fax: 925-934-2136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: RYAN MIYASAKI
Title or Position: OWNER
Credential: DDS
Phone: 925-934-3251