Provider Demographics
NPI:1992933915
Name:MIYAMASU, PATRICK KEONE (DDS)
Entity type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:KEONE
Last Name:MIYAMASU
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 1:3210 W 63RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-3325
Mailing Address - Country:US
Mailing Address - Phone:773-776-8300
Mailing Address - Fax:
Practice Address - Street 1:3210 W 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-3325
Practice Address - Country:US
Practice Address - Phone:773-776-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-29
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028007122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist