MEDICARE: DR. MATTHEW TAKASHI ODA DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DT-2834	HI

General Provider Information

NPI Number	:	1366093197
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW TAKASHI ODA DMD

Provider Business Mailing Address
First Line	:	91-791 PAPIPI RD RM 1
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-2456
Country	:	US
Telephone Number	:	808-689-7966
Fax Number	:	808-689-0966

Provider Business Practice Location Address
First Line	:	91-791 PAPIPI RD RM 1
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-2456
Country	:	US
Telephone Number	:	808-689-7966
Fax Number	:	808-689-0966

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/23/2019
Last Update Date	:	09/23/2019

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