Provider Demographics
NPI:1134666951
Name:KYLE NISHIMURA, DMD, INC
Entity Type:Organization
Organization Name:KYLE NISHIMURA, DMD, INC
Other - Org Name:ORANGE GROVE FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:NISHIMURA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:310-525-6996
Mailing Address - Street 1:16610 TAYLOR CT
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-2237
Mailing Address - Country:US
Mailing Address - Phone:310-525-6996
Mailing Address - Fax:
Practice Address - Street 1:1467 N WANDA RD STE 105
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:CA
Practice Address - Zip Code:92867-5344
Practice Address - Country:US
Practice Address - Phone:310-525-6996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62496122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty