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General NPI Number Information
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NPI Number | 1598251894
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Entity Type | Organization
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Legal Business Name | EWA BEACH DENTISTS LLC
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Dates
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Enumeration Date | 07/10/2018
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Last Update Date | 07/10/2018
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Provider Practice Location Address
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Address Line | 105 FORT WEAVER ROAD STE 105
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City | EWA BEACH
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State | HI
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Zip | 96706
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Country | US
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Telephone | 808-308-9720
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Fax |
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Provider Business Mailing Address
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Address Line | 1050 QUEEN ST STE 100
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City | HONOLULU
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State | HI
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Zip | 96814-4130
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Country | US
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Telephone | 808-202-2092
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | DR. LISA WH WONG
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Credential | DMD
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Telephone | 808-308-9720
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 2521
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License Number State | HI
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