Provider Demographics
NPI:1962817775
Name:FUKUDA, MISATO (DMD)
Entity Type:Individual
Prefix:
First Name:MISATO
Middle Name:
Last Name:FUKUDA
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 1:9600 S. IH-35 SERVICE RD
Mailing Address - Street 2:BLDG S - SUITE 275
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748
Mailing Address - Country:US
Mailing Address - Phone:855-894-4116
Mailing Address - Fax:
Practice Address - Street 1:9600 S. IH-35 SERVICE RD
Practice Address - Street 2:BLDG S - SUITE 275
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748
Practice Address - Country:US
Practice Address - Phone:855-894-4116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX307861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice