Provider Demographics
NPI:1598772386
Name:FUKUDA, JOHN TSUKURU
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:TSUKURU
Last Name:FUKUDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1435 S HIGHWAY 69
Mailing Address - Street 2:
Mailing Address - City:NEDERLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77627
Mailing Address - Country:US
Mailing Address - Phone:409-722-1496
Mailing Address - Fax:409-722-1413
Practice Address - Street 1:1435 S HWY 69
Practice Address - Street 2:
Practice Address - City:NEDERLAND
Practice Address - State:TX
Practice Address - Zip Code:77627
Practice Address - Country:US
Practice Address - Phone:409-722-1496
Practice Address - Fax:409-722-1413
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX162641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX76-0478522OtherTAX ID NUMBER