Provider Demographics
NPI:1902906530
Name:MIYASATO, LEESA S (DDS)
Entity Type:Individual
Prefix:
First Name:LEESA
Middle Name:S
Last Name:MIYASATO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65-1230 MAMALAHOA HWY STE E21
Mailing Address - Street 2:
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743-8319
Mailing Address - Country:US
Mailing Address - Phone:808-887-8801
Mailing Address - Fax:808-887-8805
Practice Address - Street 1:65-1230 MAMALAHOA HWY STE E21
Practice Address - Street 2:
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-8319
Practice Address - Country:US
Practice Address - Phone:808-887-8801
Practice Address - Fax:808-887-8805
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT13891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI138901OtherHDS PROVIDER NUMBER
HIB-06401-0OtherHMSA PROVIDER NUMBER