Basic Information
| Provider Information | |||||||||
| NPI: | 1972023968 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAIMANALO DENTISTS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HAWAII DENTAL CLINIC WAIMANALO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 S BERETANIA ST STE C117B | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968132287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085386522 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 41-1537 KALANIANAOLE HWY | ||||||||
| Address2: | |||||||||
| City: | WAIMANALO | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967951185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085386522 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2017 | ||||||||
| LastUpdateDate: | 06/21/2017 | ||||||||
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| AuthorizedOfficialLastName: | KIDO | ||||||||
| AuthorizedOfficialFirstName: | NOLAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF BUSINESS OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8085386522 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.