=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710227376
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RUSSELL K TASAKA, DMD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2013
-----------------------------------------------------
Last Update Date | 02/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3221 WAIALAE AVE STE 376
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96816-5842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-737-9032
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2024 N KING ST 107
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96819-3456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-841-7944
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RUSSELL K TASAKA
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 808-737-9032
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 1612
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------