Healthcare Provider Details

I. General information

NPI: 1396019956
Provider Name (Legal Business Name): PUKALANI DENTAL GROUP, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/29/2012
Last Update Date: 02/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3434 OLD HALEAKALA HWY
MAKAWAO HI
96768-8510
US

IV. Provider business mailing address

3434 OLD HALEAKALA HWY
MAKAWAO HI
96768-8510
US

V. Phone/Fax

Practice location:
  • Phone: 808-572-9111
  • Fax:
Mailing address:
  • Phone: 808-572-9111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1453
License Number StateHI

VIII. Authorized Official

Name: DR. KEVIN OMURO
Title or Position: DENTIST
Credential: DMD
Phone: 808-572-9111