MEDICARE: DR. MARK YUJI SHIMAO 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	1223G0001X	General Practice Dentistry	1694	HI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	721292	OTHER	HI	UNITED CONCORDIA ID #
2	1694	OTHER	HI	STATE LIC. ID #
3	81694	OTHER	HI	HDS ID #
4	K9063-5	OTHER	HI	HMSA ID #

General Provider Information

NPI Number	:	1780703827
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK YUJI SHIMAO DDS

Provider Business Mailing Address
First Line	:	91-902 FORT WEAVER RD STE 201
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-2261
Country	:	US
Telephone Number	:	808-689-6900
Fax Number	:	808-689-8330

Provider Business Practice Location Address
First Line	:	91-902 FORT WEAVER RD STE 201
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-2261
Country	:	US
Telephone Number	:	808-689-6900
Fax Number	:	808-689-8330

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

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	07/08/2007

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