Basic Information
Provider Information | |||||||||
NPI: | 1669457164 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KIMURA | ||||||||
FirstName: | TODD | ||||||||
MiddleName: | SHUJI | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1631 WETZEL AVENUE, BLDG 815 | ||||||||
Address2: | US ARMY DENTAL ACTIVITY, ATTN: FRAN GERNERT CREDENTIALS | ||||||||
City: | FORT CARSON | ||||||||
State: | CO | ||||||||
PostalCode: | 80913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195265537 | ||||||||
FaxNumber: | 7195242843 | ||||||||
Practice Location | |||||||||
Address1: | 4TH & INTERLOOP ROAD, BLDG 171 | ||||||||
Address2: | US ARMY DENTAL ACTIVITY, ATTN: FRAN GERNERT CREDENTIALS | ||||||||
City: | FORT IRWIN | ||||||||
State: | CA | ||||||||
PostalCode: | 92311 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195265537 | ||||||||
FaxNumber: | 7195242843 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/07/2005 | ||||||||
LastUpdateDate: | 08/14/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | 43803 | CA | N |   | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | 1223X0400X | DT-2429 | HI | Y |   | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.