Healthcare Provider Details

I. General information

NPI: 1073928305
Provider Name (Legal Business Name): BIG KAHUNA DENTAL, LLC DBA ALOHA DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 03/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2792 S 5600 W
WEST VALLEY CITY UT
84120-5590
US

IV. Provider business mailing address

2792 S 5600 W
WEST VALLEY CITY UT
84120-5590
US

V. Phone/Fax

Practice location:
  • Phone: 801-969-9669
  • Fax: 801-969-9779
Mailing address:
  • Phone: 801-969-9669
  • Fax: 801-969-9779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number317724-8903
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5672733-9922
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8919236-9921
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number9474332-9922
License Number StateUT
# 5
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number135181-9924
License Number StateUT
# 6
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number7579613-9923
License Number StateUT

VIII. Authorized Official

Name: KASE PEERY
Title or Position: BUSINESS MANAGER
Credential:
Phone: 801-969-9669