Provider Demographics
NPI:1871630673
Name:MIYAMOTO, ROY (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:
Last Name:MIYAMOTO
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 1:65 TAVELLA PL
Mailing Address - Street 2:
Mailing Address - City:FOOTHILL RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92610-2206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:323-249-7565
Practice Address - Street 1:4444 TWEEDY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-6304
Practice Address - Country:US
Practice Address - Phone:323-564-2444
Practice Address - Fax:323-249-7565
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA336331223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD33633Medicaid