Provider Demographics
NPI:1720107154
Name:YAMAGUCHI, JIMMIE SUYATO (DDS)
Entity type:Individual
Prefix:DR
First Name:JIMMIE
Middle Name:SUYATO
Last Name:YAMAGUCHI
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 1:2243 MOWRY AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538
Mailing Address - Country:US
Mailing Address - Phone:510-792-9084
Mailing Address - Fax:510-792-9620
Practice Address - Street 1:2243 MOWRY AVE
Practice Address - Street 2:SUITE C
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538
Practice Address - Country:US
Practice Address - Phone:510-799-9084
Practice Address - Fax:510-792-9620
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17416122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist