Healthcare Provider Details

I. General information

NPI: 1013100551
Provider Name (Legal Business Name): MATTHEW MIZUKAWA D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2007
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1623 THE VANDERBILT CLINIC
NASHVILLE TN
37232-0001
US

IV. Provider business mailing address

1623 THE VANDERBILT CLINIC
NASHVILLE TN
37232-0001
US

V. Phone/Fax

Practice location:
  • Phone: 615-343-9403
  • Fax:
Mailing address:
  • Phone: 615-343-9403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberTN 9578
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: