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General NPI Number Information
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NPI Number | 1003228982
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Entity Type | Organization
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Legal Business Name | WAIKOLOA DENTAL CLINIC INC
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Dates
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Enumeration Date | 05/27/2014
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Last Update Date | 05/27/2014
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Provider Practice Location Address
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Address Line | 69-201 WAIKOLOA BEACH DR STE 2615
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City | WAIKOLOA
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State | HI
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Zip | 96738-5815
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Country | US
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Telephone | 808-886-0891
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Fax | 808-886-0892
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Provider Business Mailing Address
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Address Line | 69-201 WAIKOLOA BEACH DRIVE # 2615
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City | WAIKOLOA
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State | HI
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Zip | 96738
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Country | US
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Telephone | 808-886-0891
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Fax | 808-886-0892
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | DR. CRAIG G FOSTVEDT
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Credential | DDS
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Telephone | 808-886-0891
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DT 1606
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License Number State | HI
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