Provider Demographics
NPI:1033995279
Name:ISHIGURO, DAIZO (DDS)
Entity Type:Individual
Prefix:
First Name:DAIZO
Middle Name:
Last Name:ISHIGURO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 FARM SPRINGS RD APT 415
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-2594
Mailing Address - Country:US
Mailing Address - Phone:210-204-5708
Mailing Address - Fax:
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-0001
Practice Address - Country:US
Practice Address - Phone:860-679-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-05
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT13902390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program