Healthcare Provider Details

I. General information

NPI: 1629816814
Provider Name (Legal Business Name): JENNIFER VEIGA BANNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2024
Last Update Date: 07/20/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3270 WAIALAE AVE
HONOLULU HI
96816-5836
US

IV. Provider business mailing address

1646 KELIIPONI LN
WAHIAWA HI
96786-7080
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number020.017018
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2284
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: