Provider Demographics
NPI:1043665219
Name:AGARI, KIMIKO
Entity Type:Individual
Prefix:
First Name:KIMIKO
Middle Name:
Last Name:AGARI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6213 EMBARCADERO DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-3823
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 N STATE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-1001
Practice Address - Country:US
Practice Address - Phone:209-482-7872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-25
Last Update Date:2024-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS100623204E00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program