Provider Demographics
NPI:1063609451
Name:SHITABATA, JED PK (DMD)
Entity type:Individual
Prefix:DR
First Name:JED
Middle Name:PK
Last Name:SHITABATA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 KAPIOLANI BLVD
Mailing Address - Street 2:SUITE 602
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-4402
Mailing Address - Country:US
Mailing Address - Phone:808-949-1995
Mailing Address - Fax:
Practice Address - Street 1:1441 KAPIOLANI BLVD
Practice Address - Street 2:SUITE 602
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-4402
Practice Address - Country:US
Practice Address - Phone:808-949-1995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT-15611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice