Healthcare Provider Details

I. General information

NPI: 1720573165
Provider Name (Legal Business Name): MILILANI DENTISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 06/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95-390 KUAHELANI AVE # 4E95-390
MILILANI HI
96789-1192
US

IV. Provider business mailing address

1050 QUEEN ST STE 100
HONOLULU HI
96814-4130
US

V. Phone/Fax

Practice location:
  • Phone: 808-538-6522
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDT2521
License Number StateHI

VIII. Authorized Official

Name: DR. LISA WH WONG
Title or Position: MANAGER
Credential: DMD
Phone: 808-538-6522