Provider Demographics
NPI:1730219106
Name:SHIBATA, FUMIO (DDS)
Entity type:Individual
Prefix:DR
First Name:FUMIO
Middle Name:
Last Name:SHIBATA
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:PO BOX 4447
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94913-4447
Mailing Address - Country:US
Mailing Address - Phone:415-608-7823
Mailing Address - Fax:
Practice Address - Street 1:2200 LARKSPUR LANDING CIRCLE
Practice Address - Street 2:SUITE 103
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939
Practice Address - Country:US
Practice Address - Phone:415-608-7823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA160471223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics