Provider Demographics
NPI:1659484582
Name:HIRAYAMA, SHIRLEY SUMIKO (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:SUMIKO
Last Name:HIRAYAMA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:SHIRLEY
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2117 FOOTHILL BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-2902
Mailing Address - Country:US
Mailing Address - Phone:909-593-7171
Mailing Address - Fax:909-593-7603
Practice Address - Street 1:2117 FOOTHILL BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-2902
Practice Address - Country:US
Practice Address - Phone:909-593-7171
Practice Address - Fax:909-593-7603
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA320931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice