Basic Information
| Provider Information | |||||||||
| NPI: | 1548498686 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PINE | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 75-5751 KUAKINI HWY STE 203 | ||||||||
| Address2: | |||||||||
| City: | KAILUA KONA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967401753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8083265629 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 74-5214 KEANALEHU DR | ||||||||
| Address2: | |||||||||
| City: | KAILUA KONA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8083555650 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2009 | ||||||||
| LastUpdateDate: | 02/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 14658 | MD | N | Dental Providers | Dentist | 122300000X | DT-2404 | HI | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 534819-01 | 05 | HI | MEDICAID | 687121 | 05 | HI | MEDICAID |