MEDICARE: HOWARD M MIZUTA DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	4776	WA

General Provider Information

NPI Number	:	1053305953
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOWARD M MIZUTA DDS

Provider Business Mailing Address
First Line	:	2100 E SECTION ST
Second Line	:	#101
City	:	MOUNT VERNON
State	:	WA
Zip	:	98274-9132
Country	:	US
Telephone Number	:	360-424-1990
Fax Number	:	360-424-1994

Provider Business Practice Location Address
First Line	:	2100 E SECTION ST
Second Line	:	#101
City	:	MOUNT VERNON
State	:	WA
Zip	:	98274-9132
Country	:	US
Telephone Number	:	360-424-1990
Fax Number	:	360-424-1994

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	07/08/2007

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