Healthcare Provider Details

I. General information

NPI: 1780188672
Provider Name (Legal Business Name): MIZUNO FAMILY DENTISTRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2018
Last Update Date: 11/07/2025
Certification Date: 11/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 W EXCHANGE PKWY STE 170
ALLEN TX
75013-7020
US

IV. Provider business mailing address

915 W EXCHANGE PKWY STE 170
ALLEN TX
75013-7020
US

V. Phone/Fax

Practice location:
  • Phone: 972-424-3064
  • Fax:
Mailing address:
  • Phone: 972-424-3064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22692
License Number StateTX

VIII. Authorized Official

Name: DAIGO MIZUNO
Title or Position: MANAGER
Credential:
Phone: 972-424-3064