Healthcare Provider Details

I. General information

NPI: 1245870526
Provider Name (Legal Business Name): OUIDA SEARAY VAILLANCOURT RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: OUIDA SEARAY VAILLANCOURT

II. Dates (important events)

Enumeration Date: 01/14/2020
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

339 MONGOMERY AVE
HONOLULU HI
96819
US

IV. Provider business mailing address

92-100 WAIPAHE PL SLIP B-10
KAPOLEI HI
96707-4293
US

V. Phone/Fax

Practice location:
  • Phone: 808-438-5555
  • Fax:
Mailing address:
  • Phone: 585-678-5248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number020870-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: