Healthcare Provider Details

I. General information

NPI: 1972075760
Provider Name (Legal Business Name): ORTHODONTIC ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2018
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date: 09/30/2024
Reactivation Date: 10/28/2024

III. Provider practice location address

505 FRONT ST STE 202
LAHAINA HI
96761
US

IV. Provider business mailing address

285 W KAAHUMANU AVE STE 220
KAHULUI HI
96732-1623
US

V. Phone/Fax

Practice location:
  • Phone: 808-874-9229
  • Fax: 808-961-2805
Mailing address:
  • Phone: 808-874-9229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ALEXANDER VERGA
Title or Position: DOCTOR/OWNER
Credential:
Phone: 808-961-6662