=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346570330
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERIOCARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2010
-----------------------------------------------------
Last Update Date | 01/13/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 AULIKE ST STE 501
-----------------------------------------------------
City | KAILUA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96734-2752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-263-1100
-----------------------------------------------------
Fax | 808-263-0111
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 AULIKE ST STE 501
-----------------------------------------------------
City | KAILUA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96734-2752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-263-1100
-----------------------------------------------------
Fax | 808-263-0111
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BRADEN C SEAMONS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 808-263-1100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 1859
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------