Provider Demographics
NPI:1700902483
Name:YAMAGATA, PEGGY B (RDH)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:B
Last Name:YAMAGATA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12533 SAN BRUNO CV
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2287
Mailing Address - Country:US
Mailing Address - Phone:858-755-8842
Mailing Address - Fax:
Practice Address - Street 1:7334 GIRARD AVE
Practice Address - Street 2:#104
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-5141
Practice Address - Country:US
Practice Address - Phone:858-459-3381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4409124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist