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General NPI Number Information
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NPI Number | 1912272063
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Entity Type | Organization
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Legal Business Name | LEEWARD PEDODONTIX, LLC
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Dates
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Enumeration Date | 03/21/2012
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Last Update Date | 03/21/2012
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Provider Practice Location Address
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Address Line | 94-229 WAIPAHU DEPOT ST SUITE #501
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City | WAIPAHU
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State | HI
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Zip | 96797-3031
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Country | US
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Telephone | 808-671-0055
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Fax | 808-671-3443
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Provider Business Mailing Address
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Address Line | 94-229 WAIPAHU DEPOT ST SUITE #501
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City | WAIPAHU
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State | HI
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Zip | 96797-3031
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Country | US
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Telephone | 808-671-0055
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Fax | 808-671-3443
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Authorized Official
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Title or Position | ASSISTANT FINANCIAL COORDINATOR
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Name | MRS. CHERYLYNN JUAN
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Credential |
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Telephone | 808-671-0055
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 1580
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License Number State | HI
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