MEDICARE: DR. GLENN A. MITOMA D.D.S.

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	25598	CA

General Provider Information

NPI Number	:	1770704140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLENN A. MITOMA D.D.S.

Provider Business Mailing Address
First Line	:	712 N EUCLID AVE
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91762-2712
Country	:	US
Telephone Number	:	909-984-3126
Fax Number	:	909-984-9416

Provider Business Practice Location Address
First Line	:	712 N EUCLID AVE
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91762-2712
Country	:	US
Telephone Number	:	909-984-3126
Fax Number	:	909-984-9416

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

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	07/08/2007

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