Healthcare Provider Details

I. General information

NPI: 1083094601
Provider Name (Legal Business Name): LYLE T. TENJOMA DDS, MSD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2015
Last Update Date: 06/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91-902 FORT WEAVER RD STE 208
EWA BEACH HI
96706-2261
US

IV. Provider business mailing address

91-902 FORT WEAVER RD STE 208
EWA BEACH HI
96706-2261
US

V. Phone/Fax

Practice location:
  • Phone: 808-689-7964
  • Fax:
Mailing address:
  • Phone: 808-689-7964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1262
License Number StateHI

VIII. Authorized Official

Name: DR. LYLE T. TENJOMA
Title or Position: OWNER
Credential: DDS, MSD
Phone: 808-941-4511