Healthcare Provider Details

I. General information

NPI: 1811059546
Provider Name (Legal Business Name): RICHARD GORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 KAWAIHAU RD STE D
KAPAA HI
96746-1964
US

IV. Provider business mailing address

PO BOX 3990
LIHUE HI
96766
US

V. Phone/Fax

Practice location:
  • Phone: 808-240-0180
  • Fax: 808-822-9298
Mailing address:
  • Phone: 808-240-0100
  • Fax: 808-245-8867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberCSDT-16
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: