Provider Demographics
NPI:1356453781
Name:MIYAMOTO, GERALD (DDS)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:
Last Name:MIYAMOTO
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 1:3257 CAMINO DE LOS COCHES
Mailing Address - Street 2:SUITE 302
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009
Mailing Address - Country:US
Mailing Address - Phone:760-942-5888
Mailing Address - Fax:760-942-5889
Practice Address - Street 1:3257 CAMINO DE LOS COCHES
Practice Address - Street 2:SUITE 302
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92009-8976
Practice Address - Country:US
Practice Address - Phone:760-942-5888
Practice Address - Fax:760-942-5889
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA472911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice