=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376730143
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAKANARI MIYAMOTO DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2007
-----------------------------------------------------
Last Update Date | 05/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12110 PORT GRACE BLVD STE 202
-----------------------------------------------------
City | LA VISTA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68128-3190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-614-7022
-----------------------------------------------------
Fax | 402-614-7122
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12110 PORT GRACE BLVD STE 202
-----------------------------------------------------
City | LA VISTA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68128-3190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 6823
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------