Provider Demographics
NPI:1558510156
Name:SHIDARA, CHIYO (DDS)
Entity Type:Individual
Prefix:
First Name:CHIYO
Middle Name:
Last Name:SHIDARA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 ALHAMBRA AVE
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-3156
Mailing Address - Country:US
Mailing Address - Phone:925-370-5200
Mailing Address - Fax:
Practice Address - Street 1:2500 ALHAMBRA AVE
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-3156
Practice Address - Country:US
Practice Address - Phone:925-370-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-18
Last Update Date:2015-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48997122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist