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General NPI Number Information
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NPI Number | 1417330978
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Entity Type | Individual
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Provider Name | JASON BEN NISHIKUBO D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/02/2015
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Last Update Date | 12/30/2025
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Provider Practice Location Address
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Address Line | 72650 FRED WARING DR STE 107
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City | PALM DESERT
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State | CA
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Zip | 92260-5007
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Country | US
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Telephone | 760-341-8414
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Fax |
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Provider Business Mailing Address
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Address Line | 72650 FRED WARING DR STE 107
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City | PALM DESERT
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State | CA
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Zip | 92260-5007
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Country | US
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Telephone | 760-341-8414
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DT2601
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License Number State | HI
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DT2601
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License Number State | HI
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