Healthcare Provider Details

I. General information

NPI: 1790135580
Provider Name (Legal Business Name): DR. TRAVIS TANAKA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 WAIALAE AVE STE 309
HONOLULU HI
96816-5316
US

IV. Provider business mailing address

4211 WAIALAE AVE STE 309
HONOLULU HI
96816-5316
US

V. Phone/Fax

Practice location:
  • Phone: 808-732-9232
  • Fax:
Mailing address:
  • Phone: 808-732-9233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3071
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: