Healthcare Provider Details

I. General information

NPI: 1952301509
Provider Name (Legal Business Name): EUGENE YUKITO YAMAGUMA D.D.S., M.S.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1885 MAIN ST STE. 208
WAILUKU HI
96793-1819
US

IV. Provider business mailing address

1885 MAIN ST STE. 208
WAILUKU HI
96793-1819
US

V. Phone/Fax

Practice location:
  • Phone: 808-242-4774
  • Fax: 808-242-8445
Mailing address:
  • Phone: 808-242-4774
  • Fax: 808-242-8445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number01030
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: