Provider Demographics
NPI:1124351630
Name:MIYATAKE, DAVID MINORU (DDS)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:MINORU
Last Name:MIYATAKE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22626 SE 216TH PL
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-6446
Mailing Address - Country:US
Mailing Address - Phone:425-432-3382
Mailing Address - Fax:
Practice Address - Street 1:22626 SE 216TH PL
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-6446
Practice Address - Country:US
Practice Address - Phone:425-432-3382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-15
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00005666122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist