Provider Demographics
NPI:1013135177
Name:KEVIN M. MIZOGUCHI, DDS, LLC
Entity Type:Organization
Organization Name:KEVIN M. MIZOGUCHI, DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MIZOGUCHI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:808-596-8020
Mailing Address - Street 1:615 PIIKOI ST
Mailing Address - Street 2:SUITE 507
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-3116
Mailing Address - Country:US
Mailing Address - Phone:808-596-8020
Mailing Address - Fax:808-597-6149
Practice Address - Street 1:615 PIIKOI ST
Practice Address - Street 2:SUITE 507
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-3116
Practice Address - Country:US
Practice Address - Phone:808-596-8020
Practice Address - Fax:808-597-6149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT-14501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty