Basic Information
| Provider Information | |||||||||
| NPI: | 1760869622 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DO | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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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: | 68-1845 WAIKOLOA RD STE 205 | ||||||||
| Address2: | |||||||||
| City: | WAIKOLOA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967385581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086570844 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2015 | ||||||||
| LastUpdateDate: | 02/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 11677 | CT | N | Dental Providers | Dentist | General Practice | 1223P0221X | 32478 | TX | N | Dental Providers | Dentist | Pediatric Dentistry | 1223P0221X | 98 | HI | N | Dental Providers | Dentist | Pediatric Dentistry | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1223P0221X | 2874 | HI | Y | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
| ID | Type | State | Issuer | Description | 830465 | 05 | HI | MEDICAID |