Provider Demographics
NPI:1740498526
Name:MIYAMOTO AND PHI DENTAL CORPORATION
Entity type:Organization
Organization Name:MIYAMOTO AND PHI DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:MIYAMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:858-454-5822
Mailing Address - Street 1:470 NAUTILUS ST
Mailing Address - Street 2:SUITE 309
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-5969
Mailing Address - Country:US
Mailing Address - Phone:858-454-5822
Mailing Address - Fax:
Practice Address - Street 1:470 NAUTILUS ST
Practice Address - Street 2:SUITE 309
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-5969
Practice Address - Country:US
Practice Address - Phone:858-454-5822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA472911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty