Basic Information
| Provider Information | |||||||||
| NPI: | 1073928305 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BIG KAHUNA DENTAL, LLC DBA ALOHA DENTAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2792 S 5600 W | ||||||||
| Address2: | |||||||||
| City: | WEST VALLEY CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841205590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019699669 | ||||||||
| FaxNumber: | 8019699779 | ||||||||
| Practice Location | |||||||||
| Address1: | 2792 S 5600 W | ||||||||
| Address2: | |||||||||
| City: | WEST VALLEY CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841205590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019699669 | ||||||||
| FaxNumber: | 8019699779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2014 | ||||||||
| LastUpdateDate: | 03/23/2016 | ||||||||
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| AuthorizedOfficialLastName: | PEERY | ||||||||
| AuthorizedOfficialFirstName: | KASE | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8019699669 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | 317724-8903 | UT | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | 1223G0001X | 5672733-9922 | UT | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 1223G0001X | 8919236-9921 | UT | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 1223P0221X | 9474332-9922 | UT | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry | 1223S0112X | 135181-9924 | UT | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223P0221X | 7579613-9923 | UT | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.