Healthcare Provider Details

I. General information

NPI: 1053305953
Provider Name (Legal Business Name): HOWARD M MIZUTA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 E SECTION ST #101
MOUNT VERNON WA
98274-9132
US

IV. Provider business mailing address

2100 E SECTION ST #101
MOUNT VERNON WA
98274-9132
US

V. Phone/Fax

Practice location:
  • Phone: 360-424-1990
  • Fax: 360-424-1994
Mailing address:
  • Phone: 360-424-1990
  • Fax: 360-424-1994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4776
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: