=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275393829
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KONA PERIODONTICS AND IMPLANTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2024
-----------------------------------------------------
Last Update Date | 03/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 77-6447 KUAKINI HWY
-----------------------------------------------------
City | KAILUA KONA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96740-2227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-329-7246
-----------------------------------------------------
Fax | 808-461-3925
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1974 MOHOULI ST
-----------------------------------------------------
City | HILO
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96720-1924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | JEREMY OAKLEY
-----------------------------------------------------
Credential | DDS, MSD
-----------------------------------------------------
Telephone | 410-459-4046
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------