Healthcare Provider Details

I. General information

NPI: 1831324490
Provider Name (Legal Business Name): PERIODONTICS, A PROF. CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2009
Last Update Date: 05/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 WAIALAE AVE. SUITE 401
HONOLULU HI
96816
US

IV. Provider business mailing address

4211 WAIALAE AVE. SUITE 401
HONOLULU HI
96816
US

V. Phone/Fax

Practice location:
  • Phone: 808-732-2224
  • Fax:
Mailing address:
  • Phone: 808-732-2224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number641
License Number StateHI

VIII. Authorized Official

Name: DR. EARL WILLIAM AH MOO
Title or Position: OWNER
Credential: D.D.S., M.S.
Phone: 808-373-9404