Provider Demographics
NPI:1053545012
Name:NISHIMURA, BRYAN ICHIRO (DMD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:ICHIRO
Last Name:NISHIMURA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 PALI HIGHWAY
Mailing Address - Street 2:SUITE 207
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813
Mailing Address - Country:US
Mailing Address - Phone:808-536-7449
Mailing Address - Fax:
Practice Address - Street 1:1300 PALI HIGHWAY
Practice Address - Street 2:SUITE 207
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813
Practice Address - Country:US
Practice Address - Phone:808-536-7449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI996122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist