Healthcare Provider Details

I. General information

NPI: 1487885166
Provider Name (Legal Business Name): HAWAII DENTAL IMPLANT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2009
Last Update Date: 09/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 WAIALAE AVE SUITE 102
HONOLULU HI
96816-5319
US

IV. Provider business mailing address

4211 WAIALAE AVE SUITE 102
HONOLULU HI
96816-5319
US

V. Phone/Fax

Practice location:
  • Phone: 808-737-6150
  • Fax:
Mailing address:
  • Phone: 808-737-6150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDT-2153
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDT-2153
License Number StateHI
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDT-2153
License Number StateHI

VIII. Authorized Official

Name: DR. JMI L ASAM
Title or Position: MEMBER
Credential: DMD
Phone: 808-781-9964