MEDICARE: MRS. MARY JANE D.R. TAKEMOTO

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	124Q00000X	Dental Hygienist	DH-1027	HI

General Provider Information

NPI Number	:	1245643667
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY JANE D.R. TAKEMOTO

Provider Business Mailing Address
First Line	:	4323 LAAKEA ST
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96818-1966
Country	:	US
Telephone Number	:	808-422-4420
Fax Number	:

Provider Business Practice Location Address
First Line	:	1253 MAKALAPA GATE RD
Second Line	:
City	:	JBPHH
State	:	HI
Zip	:	96860-4479
Country	:	US
Telephone Number	:	808-473-1880
Fax Number	:

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

Provider Enumeration Date	:	06/03/2014
Last Update Date	:	06/03/2014

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