Provider Demographics
NPI:1386273282
Name:NINOMIYA, LARANDA (RDH, BS)
Entity type:Individual
Prefix:
First Name:LARANDA
Middle Name:
Last Name:NINOMIYA
Suffix:
Gender:F
Credentials:RDH, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1595 ASHEFORDE DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-1850
Mailing Address - Country:US
Mailing Address - Phone:270-452-1058
Mailing Address - Fax:
Practice Address - Street 1:1595 ASHEFORDE DR
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-1850
Practice Address - Country:US
Practice Address - Phone:270-452-1058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-03
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADH007435124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist