Healthcare Provider Details

I. General information

NPI: 1689896979
Provider Name (Legal Business Name): JOHN I KOTAKE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 S. KING ST. STE. 406
HONOLULU HI
96814
US

IV. Provider business mailing address

1150 S. KING ST. STE. 406
HONOLULU HI
96814
US

V. Phone/Fax

Practice location:
  • Phone: 808-593-8511
  • Fax: 808-593-2228
Mailing address:
  • Phone: 808-593-8511
  • Fax: 808-593-2228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number992
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: