Provider Demographics
NPI:1750974267
Name:TANIGUCHI, SHO PATRICK (MPH, DMD)
Entity type:Individual
Prefix:DR
First Name:SHO
Middle Name:PATRICK
Last Name:TANIGUCHI
Suffix:
Gender:M
Credentials:MPH, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:674 OCEAN AVE APT 205
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-1281
Mailing Address - Country:US
Mailing Address - Phone:602-635-0713
Mailing Address - Fax:
Practice Address - Street 1:269 UNION ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1314
Practice Address - Country:US
Practice Address - Phone:781-581-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-16
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN1859377122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program