Healthcare Provider Details

I. General information

NPI: 1457737272
Provider Name (Legal Business Name): WAILUKU DENTISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2015
Last Update Date: 08/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1885 MAIN ST SUITE 208
WAILUKU HI
96793
US

IV. Provider business mailing address

50 SOUTH BERETANIA ST C-117B
HONOLULU HI
96813
US

V. Phone/Fax

Practice location:
  • Phone: 808-242-4774
  • Fax:
Mailing address:
  • Phone: 808-242-4774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2545
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number1030
License Number StateHI

VIII. Authorized Official

Name: NOLAN KIDO
Title or Position: DULY AUTHORIZED AGENT
Credential:
Phone: 808-242-4774