Basic Information
| Provider Information | |||||||||
| NPI: | 1265854426 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROGER T.L. WONG LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | HAWAII DENTAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 50 S BERETANIA ST | ||||||||
| Address2: | SUITE C-117B | ||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968132208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085386522 | ||||||||
| FaxNumber: | 8085381641 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 S BERETANIA ST | ||||||||
| Address2: | SUITE C-117B | ||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968132208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085386522 | ||||||||
| FaxNumber: | 8085381641 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2014 | ||||||||
| LastUpdateDate: | 01/07/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KIDO | ||||||||
| AuthorizedOfficialFirstName: | NOLAN | ||||||||
| AuthorizedOfficialMiddleName: | Y | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 8085386522 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DT-2521 | HI | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 122300000X | DT-1290 | HI | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.