=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164807012
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEREK YUTAKA NISHIMORI D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2015
-----------------------------------------------------
Last Update Date | 06/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2000 FOREST AVE STE C
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95128-4831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-287-5900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1130 KIFER RD APT 504
-----------------------------------------------------
City | SUNNYVALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94086-5392
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-807-1044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 64661
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------