Healthcare Provider Details

I. General information

NPI: 1467135376
Provider Name (Legal Business Name): KRISTEN RENAE GRADY DENTAL HYGIENIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2023
Last Update Date: 08/08/2023
Certification Date: 08/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MONTGOMERY DRIVE #339
HONOLULU HI
96819
US

IV. Provider business mailing address

109 YASUTAKE RD
HONOLULU HI
96819-4811
US

V. Phone/Fax

Practice location:
  • Phone: 808-438-5555
  • Fax:
Mailing address:
  • Phone: 253-221-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number0402208146
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH-2431-0
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: