MEDICARE: DR. JON M NISHIKUBO 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	1223G0001X	General Practice Dentistry	45741	CA

General Provider Information

NPI Number	:	1609872191
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JON M NISHIKUBO DDS

Provider Business Mailing Address
First Line	:	1171 MURRIETA BLVD
Second Line	:	STE 201
City	:	LIVERMORE
State	:	CA
Zip	:	94550-4143
Country	:	US
Telephone Number	:	925-960-0990
Fax Number	:	925-960-9977

Provider Business Practice Location Address
First Line	:	1171 MURRIETA BLVD
Second Line	:	STE 201
City	:	LIVERMORE
State	:	CA
Zip	:	94550-4143
Country	:	US
Telephone Number	:	925-960-0990
Fax Number	:	925-960-9977

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

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	03/17/2021

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