Provider Demographics
NPI:1255425609
Name:KISHIBAY, JOHN S (DMD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:KISHIBAY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 OCEAN PARK BLVD
Mailing Address - Street 2:304
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-5210
Mailing Address - Country:US
Mailing Address - Phone:310-581-5757
Mailing Address - Fax:310-581-5759
Practice Address - Street 1:2601 OCEAN PARK BLVD
Practice Address - Street 2:304
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-5210
Practice Address - Country:US
Practice Address - Phone:310-581-5757
Practice Address - Fax:310-581-5759
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA277781223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU36417Medicare UPIN
CAWD27778Medicare ID - Type Unspecified