Healthcare Provider Details

I. General information

NPI: 1952350027
Provider Name (Legal Business Name): ILEANA CARRENO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 10/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2484 KOLO RD
KILAUEA HI
95754
US

IV. Provider business mailing address

PO BOX 746
KILAUEA HI
95754
US

V. Phone/Fax

Practice location:
  • Phone: 808-828-1863
  • Fax: 808-828-1774
Mailing address:
  • Phone: 808-828-6675
  • Fax: 808-828-1774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1133
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: