Healthcare Provider Details

I. General information

NPI: 1609907245
Provider Name (Legal Business Name): RANDALL SCOTT CISLO D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65-1279 KAWAIHAE RD SUITE 101
KAMUELA HI
96743-8444
US

IV. Provider business mailing address

65-1279 KAWAIHAE RD SUITE 101
KAMUELA HI
96743-8444
US

V. Phone/Fax

Practice location:
  • Phone: 808-885-8617
  • Fax: 808-885-9316
Mailing address:
  • Phone: 808-885-8617
  • Fax: 808-885-9316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDT1230
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: