=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184075111
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY ALEXANDRA SHIMADA D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2016
-----------------------------------------------------
Last Update Date | 03/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11301 WILSHIRE BLVD BLDG 500 DENTAL
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90073-1003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-399-5248
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25078 PEACHLAND AVE STE H
-----------------------------------------------------
City | NEWHALL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91321-2555
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | 64313
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------