=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528932654
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JET DENTAL OF HAWAII LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2025
-----------------------------------------------------
Last Update Date | 10/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1110 NUUANU AVE # A1-5263
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96817-5119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-430-9262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1110 NUUANU AVE # A1-5263
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96817-5119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-430-9262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARALEGAL
-----------------------------------------------------
Name | DARRA THOMAS-DAVIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-369-2684
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------