Healthcare Provider Details

I. General information

NPI: 1104261023
Provider Name (Legal Business Name): JOHN HIDEO MIZUKAWA II DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2013
Last Update Date: 02/08/2023
Certification Date: 02/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1308 E 900 S STE A
ST GEORGE UT
84790-8730
US

IV. Provider business mailing address

1308 E 900 S STE A
ST GEORGE UT
84790-8730
US

V. Phone/Fax

Practice location:
  • Phone: 435-673-1554
  • Fax: 435-674-9967
Mailing address:
  • Phone: 435-673-1554
  • Fax: 865-482-8686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12918932
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: