Individual
DARRON IKARI MIYA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
159 W HOSPITALITY LN, SAN BERNARDINO, CA 92408-3348
(909) 558-4616
Mailing address
828 MALONE DR, MONTEBELLO, CA 90640-2424
Taxonomy
Speciality
Code
Description
License number
State
1223X0400X
Orthodontics and Dentofacial Orthopedics Dentistry
Primary
104627
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
104627
CALIFORNIA DENTAL BOARD
CA
Enumeration date
08/18/2020
Last updated
09/10/2020
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