MEDICARE: DR. EVANGELINE UY SHITABATA DDS

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	1223P0221X	Pediatric Dentistry	40037	CA

General Provider Information

NPI Number	:	1376543835
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EVANGELINE UY SHITABATA DDS

Provider Business Mailing Address
First Line	:	23451 MADISON ST
Second Line	:	#170
City	:	TORRANCE
State	:	CA
Zip	:	90505-4763
Country	:	US
Telephone Number	:	310-375-5437
Fax Number	:	310-375-7608

Provider Business Practice Location Address
First Line	:	23451 MADISON ST
Second Line	:	#170
City	:	TORRANCE
State	:	CA
Zip	:	90505-4763
Country	:	US
Telephone Number	:	310-375-5437
Fax Number	:	310-375-7608

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

Provider Enumeration Date	:	07/27/2005
Last Update Date	:	07/08/2007

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