Provider Demographics
NPI:1306201892
Name:IZUMI, SHO
Entity Type:Individual
Prefix:
First Name:SHO
Middle Name:
Last Name:IZUMI
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 1:23545 CRENSHAW BLVD
Mailing Address - Street 2:STE 105
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-5218
Mailing Address - Country:US
Mailing Address - Phone:310-323-2320
Mailing Address - Fax:
Practice Address - Street 1:23545 CRENSHAW BLVD
Practice Address - Street 2:STE 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:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-28
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64992122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist