Provider Demographics
NPI:1609237759
Name:STASON K. SHISHIDO, D.D.S. INC.
Entity Type:Organization
Organization Name:STASON K. SHISHIDO, D.D.S. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STASON
Authorized Official - Middle Name:KATSURO
Authorized Official - Last Name:SHISHIDO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:408-294-6624
Mailing Address - Street 1:2025 FOREST AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-4806
Mailing Address - Country:US
Mailing Address - Phone:408-294-6624
Mailing Address - Fax:408-920-0937
Practice Address - Street 1:2025 FOREST AVE STE 3
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-4806
Practice Address - Country:US
Practice Address - Phone:408-294-6624
Practice Address - Fax:408-920-0937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35551261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental