Provider Demographics
NPI:1902015589
Name:OKUYAMA, JOHNNY (DDS)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:OKUYAMA
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 1:23418 LYONS AVE
Mailing Address - Street 2:
Mailing Address - City:NEWHALL
Mailing Address - State:CA
Mailing Address - Zip Code:91321-2511
Mailing Address - Country:US
Mailing Address - Phone:661-260-0833
Mailing Address - Fax:661-260-1101
Practice Address - Street 1:23418 LYONS AVE
Practice Address - Street 2:
Practice Address - City:NEWHALL
Practice Address - State:CA
Practice Address - Zip Code:91321-2511
Practice Address - Country:US
Practice Address - Phone:661-260-0833
Practice Address - Fax:661-260-1101
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD49963122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD49963OtherSTATE LICENSE