Provider Demographics
NPI:1083081236
Name:SHO IZUMI, DDS, INC
Entity Type:Organization
Organization Name:SHO IZUMI, DDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHO
Authorized Official - Middle Name:
Authorized Official - Last Name:IZUMI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-259-6740
Mailing Address - Street 1:1568 W ARTESIA SQ UNIT F
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-4735
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23545 CRENSHAW BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5218
Practice Address - Country:US
Practice Address - Phone:310-323-2320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64992261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental