=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992248942
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NIHON DENTAL GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2016
-----------------------------------------------------
Last Update Date | 11/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4122 CHATTAHOOCHEE TRCE SUITE 204
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30097-2132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-622-2288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4122 CHATTAHOOCHEE TRCE SUITE 204
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30097-2132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-622-2288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. YOSHIHITO SHIMIZU
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 770-272-1818
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122400000X
-----------------------------------------------------
Taxonomy Name | Denturist
-----------------------------------------------------
License Number | 013638
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------