Healthcare Provider Details

I. General information

NPI: 1033930441
Provider Name (Legal Business Name): MR. CAMP DENTON BULLARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2024
Last Update Date: 10/18/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 KAPAA QUARRY PL
KAILUA HI
96734
US

IV. Provider business mailing address

44-105 PUUOHALAI PL
KANEOHE HI
96744-2545
US

V. Phone/Fax

Practice location:
  • Phone: 808-247-2973
  • Fax:
Mailing address:
  • Phone: 405-391-5026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number106S00000X
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: