Provider Demographics
NPI:1164807012
Name:NISHIMORI, DEREK YUTAKA (DDS)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:YUTAKA
Last Name:NISHIMORI
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 1:1130 KIFER RD APT 504
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94086-5392
Mailing Address - Country:US
Mailing Address - Phone:805-807-1044
Mailing Address - Fax:
Practice Address - Street 1:2000 FOREST AVE STE C
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-4831
Practice Address - Country:US
Practice Address - Phone:408-287-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-21
Last Update Date:2021-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA646611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice