=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548509862
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | M HIROTA DMD A DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2013
-----------------------------------------------------
Last Update Date | 02/06/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 135 CIVIC CENTER DR 102
-----------------------------------------------------
City | NATIONAL CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91950-4357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-474-4695
-----------------------------------------------------
Fax | 619-252-4935
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 135 CIVIC CENTER DR 102
-----------------------------------------------------
City | NATIONAL CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91950-4357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-474-4695
-----------------------------------------------------
Fax | 619-252-4935
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MISAKO HIROTA
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 619-474-4695
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 35117
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------