MEDICARE: HAWAII PEDIATRIC DENTISTRY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1023742905
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAWAII PEDIATRIC DENTISTRY LLC

Provider Business Mailing Address
First Line	:	91-3575 KAULUAKOKO ST UNIT 3004
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-5857
Country	:	US
Telephone Number	:	781-951-4055
Fax Number	:

Provider Business Practice Location Address
First Line	:	91-3575 KAULUAKOKO ST UNIT 3004
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-5857
Country	:	US
Telephone Number	:	781-951-4055
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PEDIATRIC DENTIST
Name	:	DR. PETER LEE
Credential	:	DMD
Telephone Number	:	808-753-9094

Provider Enumeration Date	:	07/15/2022
Last Update Date	:	07/15/2022

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