Healthcare Provider Details

I. General information

NPI: 1558679373
Provider Name (Legal Business Name): HAWAII DENTAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2010
Last Update Date: 09/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46-056 KAMEHAMEHA HWY SUITE 288
KANEOHE HI
96744-3755
US

IV. Provider business mailing address

500 ALA MOANA BLVD SUITE 7-220
HONOLULU HI
96813-4920
US

V. Phone/Fax

Practice location:
  • Phone: 808-235-2000
  • Fax: 808-236-1050
Mailing address:
  • Phone: 808-523-3103
  • Fax: 808-523-3122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. GARY KONDO
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 808-523-3103