Provider Demographics
NPI:1790782811
Name:HIROTA, MISAKO (DMD)
Entity Type:Individual
Prefix:DR
First Name:MISAKO
Middle Name:
Last Name:HIROTA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 CIVIC CENTER DR STE 102
Mailing Address - Street 2:
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950-4357
Mailing Address - Country:US
Mailing Address - Phone:619-474-4695
Mailing Address - Fax:
Practice Address - Street 1:135 CIVIC CENTER DR STE 102
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-4357
Practice Address - Country:US
Practice Address - Phone:619-474-4695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35117122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG92697-01Medicaid