Takanari Miyamoto, DDS

Primary specialty

PeriodonticsTaxonomy code 1223P0300X

License

6823 Issued in NE

Practice address

12110 Port Grace Blvd Ste 202
La Vista, NE 68128-3190

Phone

(402) 614-7022

Fax

(402) 614-7122

NPI assigned

Sep 26, 2007

Last updated

May 27, 2010By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective Oct 28, 2020 through Oct 28, 2026

Medicare enrollment (NPD)

Enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1190764800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1274918400000",
    "number": "1376730143",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12110 PORT GRACE BLVD STE 202",
            "city": "LA VISTA",
            "state": "NE",
            "postal_code": "681283190"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12110 PORT GRACE BLVD STE 202",
            "city": "LA VISTA",
            "state": "NE",
            "postal_code": "681283190",
            "telephone_number": "402-614-7022",
            "fax_number": "402-614-7122"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MIYAMOTO",
        "first_name": "TAKANARI",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-09-26",
        "last_updated": "2010-05-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223P0300X",
            "taxonomy_group": "",
            "desc": "Dentist, Periodontics",
            "state": "NE",
            "license": "6823",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Periodontics in La Vista, NE
• Providers in La Vista, NE by specialty
• Periodontics in Nebraska

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 27, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.