Healthcare Provider Details

I. General information

NPI: 1588949259
Provider Name (Legal Business Name): ALEXANDER TARASOV D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ALEKSANDR TARASOV D.M.D.

II. Dates (important events)

Enumeration Date: 10/13/2011
Last Update Date: 02/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 WAIALAE AVE STE 111
HONOLULU HI
96816-5319
US

IV. Provider business mailing address

3270 WAIALAE AVE
HONOLULU HI
96816-5836
US

V. Phone/Fax

Practice location:
  • Phone: 808-732-4377
  • Fax:
Mailing address:
  • Phone: 808-732-4377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number61395
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDT-2628
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: