=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073986543
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAILUKU DENTAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2015
-----------------------------------------------------
Last Update Date | 11/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 255 IMI KALA ST
-----------------------------------------------------
City | WAILUKU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96793-1282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-244-8808
-----------------------------------------------------
Fax | 808-244-6032
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 255 IMI KALA ST
-----------------------------------------------------
City | WAILUKU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96793-1282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-244-8808
-----------------------------------------------------
Fax | 808-244-6032
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JONATHAN K LAU
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 808-244-8808
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 1388
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------