Healthcare Provider Details

I. General information

NPI: 1114071107
Provider Name (Legal Business Name): EARL AKIO HASEGAWA D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 S WAKEA AVE STE 103
KAHULUI HI
96732-1385
US

IV. Provider business mailing address

135 S WAKEA AVE STE 103
KAHULUI HI
96732-1385
US

V. Phone/Fax

Practice location:
  • Phone: 808-877-7775
  • Fax: 808-877-4058
Mailing address:
  • Phone: 808-877-7775
  • Fax: 808-877-4058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDT-1657
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: