Healthcare Provider Details

I. General information

NPI: 1104065085
Provider Name (Legal Business Name): KEITH A. VODZAK D.M.D. M.S.D., ORTHO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2009
Last Update Date: 02/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

377 KEAHOLE ST. SUITE #211
HONOLULU HI
96825
US

IV. Provider business mailing address

42-125 KOOKU PLACE
KAILUA HI
96734-5710
US

V. Phone/Fax

Practice location:
  • Phone: 808-393-2020
  • Fax:
Mailing address:
  • Phone: 808-393-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDT-1666
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: