Healthcare Provider Details

I. General information

NPI: 1558106922
Provider Name (Legal Business Name): JOMARC DASALLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2024
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KNEELAND ST # 1005
BOSTON MA
02111-1527
US

IV. Provider business mailing address

91-1018 KAIAU AVE # 1B
KAPOLEI HI
96707-1986
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-6828
  • Fax:
Mailing address:
  • Phone: 907-738-5638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDT-3304
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: