Provider Demographics
NPI:1891271987
Name:MIYAMOTO, COURTNEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:
Last Name:MIYAMOTO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 E JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-2856
Mailing Address - Country:US
Mailing Address - Phone:920-924-9090
Mailing Address - Fax:
Practice Address - Street 1:545 E JOHNSON ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-2856
Practice Address - Country:US
Practice Address - Phone:920-924-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT27601223G0001X
WI10019571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice