Healthcare Provider Details

I. General information

NPI: 1205558319
Provider Name (Legal Business Name): ORTHODONTIC ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2022
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1037 MAKAWAO AVE
MAKAWAO HI
96768
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: 808-791-1507

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