Healthcare Provider Details

I. General information

NPI: 1033328646
Provider Name (Legal Business Name): PACIFIC FAMILY DENTAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4429 MALAAI ST SUITE 103
HONOLULU HI
96818-3158
US

IV. Provider business mailing address

4429 MALAAI ST SUITE 103
HONOLULU HI
96818-3158
US

V. Phone/Fax

Practice location:
  • Phone: 808-422-1155
  • Fax:
Mailing address:
  • Phone: 808-422-1155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDT1923
License Number StateHI

VIII. Authorized Official

Name: DR. MARK KEKOA WATANABE
Title or Position: PRESIDENT
Credential: DDS
Phone: 808-422-1155