Healthcare Provider Details

I. General information

NPI: 1932675212
Provider Name (Legal Business Name): DEPT. OF HEALTH-HI DEVELOPMENTAL DISABILITIES H&CDSB (DENTAL)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2018
Last Update Date: 10/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 LANAKILA AVE RM 203
HONOLULU HI
96817-2115
US

IV. Provider business mailing address

1250 PUNCHBOWL ST STE 463
HONOLULU HI
96813-2416
US

V. Phone/Fax

Practice location:
  • Phone: 808-832-5710
  • Fax: 808-832-5722
Mailing address:
  • Phone: 808-586-5842
  • Fax: 808-586-5844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MARY BROGAN
Title or Position: DDD ADMINISTRATOR
Credential:
Phone: 808-586-5842