Healthcare Provider Details

I. General information

NPI: 1578793006
Provider Name (Legal Business Name): RYAN MASAO MIZUMOTO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2009
Last Update Date: 01/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 CAREN AVE STE 270
WORTHINGTON OH
43085-2515
US

IV. Provider business mailing address

6779 OAKFAIR AVE
COLUMBUS OH
43235-2734
US

V. Phone/Fax

Practice location:
  • Phone: 614-885-7721
  • Fax: 614-888-0284
Mailing address:
  • Phone: 206-920-6173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019028088
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30-023250
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number30-023250
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: