Provider Demographics
NPI:1578793006
Name:MIZUMOTO, RYAN MASAO (DMD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:MASAO
Last Name:MIZUMOTO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6779 OAKFAIR AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-2734
Mailing Address - Country:US
Mailing Address - Phone:206-920-6173
Mailing Address - Fax:
Practice Address - Street 1:55 CAREN AVE STE 270
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-2515
Practice Address - Country:US
Practice Address - Phone:614-885-7721
Practice Address - Fax:614-888-0284
Is Sole Proprietor?:No
Enumeration Date:2009-07-17
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028088122300000X
OH30-0232501223G0001X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice