Healthcare Provider Details

I. General information

NPI: 1093374696
Provider Name (Legal Business Name): ISLAND ORAL AND MAXILLOFACIAL SURGERY, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 06/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 KAMOKILA BLVD STE 203
KAPOLEI HI
96707-2055
US

IV. Provider business mailing address

338 KAMOKILA BLVD STE 203
KAPOLEI HI
96707-2055
US

V. Phone/Fax

Practice location:
  • Phone: 808-674-2255
  • Fax: 808-674-1771
Mailing address:
  • Phone: 808-674-2255
  • Fax: 808-674-1771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. MATTHEW SCOTT ABRAHAM
Title or Position: OWNER
Credential: DDS, MD
Phone: 808-674-2255