MEDICARE: LENA POONNOPATAM DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DT-2923	HI

General Provider Information

NPI Number	:	1215500939
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LENA POONNOPATAM DDS

Provider Business Mailing Address
First Line	:	55 S KUKUI ST APT D1905
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96813-2367
Country	:	US
Telephone Number	:	661-755-6291
Fax Number	:

Provider Business Practice Location Address
First Line	:	91-1121 KEAUNUI DR STE 112
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-6365
Country	:	US
Telephone Number	:	808-748-4971
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2021
Last Update Date	:	07/20/2021

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