Provider Demographics
NPI:1780703827
Name:SHIMAO, MARK YUJI (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:YUJI
Last Name:SHIMAO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-902 FORT WEAVER RD STE 201
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-2261
Mailing Address - Country:US
Mailing Address - Phone:808-689-6900
Mailing Address - Fax:808-689-8330
Practice Address - Street 1:91-902 FORT WEAVER RD STE 201
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-2261
Practice Address - Country:US
Practice Address - Phone:808-689-6900
Practice Address - Fax:808-689-8330
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI16941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI721292OtherUNITED CONCORDIA ID #
HI1694OtherSTATE LIC. ID #
HI81694OtherHDS ID #
HIK9063-5OtherHMSA ID #
HIK9063-5OtherHMSA ID #