=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780188672
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIZUNO FAMILY DENTISTRY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2018
-----------------------------------------------------
Last Update Date | 11/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 915 W EXCHANGE PKWY STE 170
-----------------------------------------------------
City | ALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75013-7020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-424-3064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 915 W EXCHANGE PKWY STE 170
-----------------------------------------------------
City | ALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75013-7020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-424-3064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DAIGO MIZUNO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-424-3064
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 22692
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------