MEDICARE: MELVIN H TAKAKI

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	DD2104	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	912997	OTHER	NM	UNITED CONCORDIA
2	0009883	OTHER	NM	DORAL
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588739916
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELVIN H TAKAKI

Provider Business Mailing Address
First Line	:	415 N GRAND AVE
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81003-3111
Country	:	US
Telephone Number	:	719-583-1800
Fax Number	:

Provider Business Practice Location Address
First Line	:	2008 SAINT MICHAELS DR
Second Line	:	#B
City	:	SANTA FE
State	:	NM
Zip	:	87505-7682
Country	:	US
Telephone Number	:	505-474-4993
Fax Number	:

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

Provider Enumeration Date	:	11/21/2006
Last Update Date	:	07/09/2007

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Directions to “ MELVIN H TAKAKI ” Practice Location

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