Provider Demographics
NPI:1245367234
Name:MIYAWAKI, STANLEY MITSUO (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:MITSUO
Last Name:MIYAWAKI
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11980 SAN VICENTE BLVD.
Mailing Address - Street 2:SUITE 602
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-6604
Mailing Address - Country:US
Mailing Address - Phone:310-826-6694
Mailing Address - Fax:310-826-3602
Practice Address - Street 1:11980 SAN VICENTE BLVD.
Practice Address - Street 2:SUITE 602
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-6604
Practice Address - Country:US
Practice Address - Phone:310-826-6694
Practice Address - Fax:310-826-3602
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA309791223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics