Provider Demographics
NPI:1801026885
Name:MITOMA, EDWARD ARTHUR (DDS)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:ARTHUR
Last Name:MITOMA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4423 FIRST ST
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94551-4915
Mailing Address - Country:US
Mailing Address - Phone:925-449-1768
Mailing Address - Fax:925-449-2065
Practice Address - Street 1:4423 FIRST ST
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94551-4915
Practice Address - Country:US
Practice Address - Phone:925-449-1768
Practice Address - Fax:925-449-2065
Is Sole Proprietor?:No
Enumeration Date:2009-07-23
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA406801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice