Healthcare Provider Details

I. General information

NPI: 1124854757
Provider Name (Legal Business Name): DANETTE MABASA AGCAOILI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 09/10/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

459 PATTERSON RD
HONOLULU HI
96819-1522
US

IV. Provider business mailing address

91-1149 KAILEONUI ST
EWA BEACH HI
96706-6048
US

V. Phone/Fax

Practice location:
  • Phone: 808-433-0600
  • Fax:
Mailing address:
  • Phone: 808-391-1846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH1593
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: