=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083761118
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AW DENTAL GROUP , INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2226 LILIHA ST SUITE 303
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96817-1600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-538-1190
-----------------------------------------------------
Fax | 808-538-3843
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2226 LILIHA ST SUITE 303
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96817-1600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-538-1190
-----------------------------------------------------
Fax | 808-538-3843
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ALDRIN B.L. WONG
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 808-538-1190
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DT-1802
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------