Healthcare Provider Details

I. General information

NPI: 1295108280
Provider Name (Legal Business Name): ISLAND DENTAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2015
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98-1247 KAAHUMANU ST SUITE 214
AIEA HI
96701-5311
US

IV. Provider business mailing address

98-1247 KAAHUMANU ST SUITE 214
AIEA HI
96701-5311
US

V. Phone/Fax

Practice location:
  • Phone: 808-484-4470
  • Fax: 808-484-4462
Mailing address:
  • Phone: 808-484-4470
  • Fax: 808-484-4462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDT 1744
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. CLAUDE NOBORU TAMURA
Title or Position: PRESIDENT/OWNER
Credential: D.D.S.
Phone: 808-484-4470