Healthcare Provider Details

I. General information

NPI: 1790740322
Provider Name (Legal Business Name): JOHN W ETZENBACH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 02/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JARRETT WHITE RD BLDG 320 US ARMY DENTAL ACTIVITY
TRIPLER AMC HI
96859-5001
US

IV. Provider business mailing address

1 JARRETT WHITE RD BLDG 320 US ARMY DENTAL ACTIVITY
TRIPLER AMC HI
96859-5001
US

V. Phone/Fax

Practice location:
  • Phone: 808-433-9200
  • Fax: 808-433-9194
Mailing address:
  • Phone: 808-433-9200
  • Fax: 808-433-9194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number019018177
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2192
License Number StateHI
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number52815
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: