Provider Demographics
NPI:1508075086
Name:PHI AND MIYAMOTO DENTAL CORPORATION
Entity Type:Organization
Organization Name:PHI AND MIYAMOTO DENTAL CORPORATION
Other - Org Name:LA COSTA DEL SUR DENTAL PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:MIYAMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-942-5888
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:92009-8966
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
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:92009-8966
Practice Address - Country:US
Practice Address - Phone:760-942-5888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA472911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty