=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003800137
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY MIYAKE DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2005
-----------------------------------------------------
Last Update Date | 07/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7234 N SEQUOIA AVE
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93711-0450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-246-4195
-----------------------------------------------------
Fax | 559-447-1813
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7234 N SEQUOIA AVE
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93711-0450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-246-4195
-----------------------------------------------------
Fax | 559-447-1813
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 26209
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------