Healthcare Provider Details

I. General information

NPI: 1538150099
Provider Name (Legal Business Name): KENN KANESHIRO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 08/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18TH MEDICAL GROUP UNIT 5142
APO AP
96368-5142
US

IV. Provider business mailing address

PSC 80 BOX 13688
APO AP
96367-9998
US

V. Phone/Fax

Practice location:
  • Phone: 98-960-4650
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDT 1907
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: