Basic Information
| Provider Information | |||||||||
| NPI: | 1275951618 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HAWAII DENTAL CLINIC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 50 S BERETANIA ST | ||||||||
| Address2: | C-117B | ||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968132208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085386522 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 50 S BERETANIA ST | ||||||||
| Address2: | C-117B | ||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968132208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085386522 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2014 | ||||||||
| LastUpdateDate: | 04/02/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WONG | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | WH | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8085386522 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DMD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 1290 | HI | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 122300000X | 2521 | HI | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.