Basic Information
| Provider Information | |||||||||
| NPI: | 1710386115 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOAL | ||||||||
| FirstName: | STEPHANIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 87-931 KULAKOA ST | ||||||||
| Address2: | |||||||||
| City: | WAIANAE | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967923307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5154735065 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 86-260 FARRINGTON HWY | ||||||||
| Address2: | |||||||||
| City: | WAIANAE | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967923128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086973496 | ||||||||
| FaxNumber: | 8086978020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2014 | ||||||||
| LastUpdateDate: | 08/21/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 2009017104 | MO | N | Dental Providers | Dental Hygienist | 124Q00000X | 8 | MO | Y | Dental Providers | Dental Hygienist |
No ID Information.