Provider Demographics
NPI:1366652257
Name:ICHIUJI, JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:ICHIUJI
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 1:9260 ALCOSTA BLVD
Mailing Address - Street 2:SUITE D-30
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-4134
Mailing Address - Country:US
Mailing Address - Phone:925-828-6300
Mailing Address - Fax:
Practice Address - Street 1:9260 ALCOSTA BLVD
Practice Address - Street 2:SUITE D-30
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-4134
Practice Address - Country:US
Practice Address - Phone:925-828-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA276361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice