MEDICARE: LYLE T. TENJOMA DDS, MSD

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	122300000X	Dentist	1262	HI

General Provider Information

NPI Number	:	1083094601
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LYLE T. TENJOMA DDS, MSD

Provider Business Mailing Address
First Line	:	91-902 FORT WEAVER RD STE 208
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-2261
Country	:	US
Telephone Number	:	808-689-7964
Fax Number	:

Provider Business Practice Location Address
First Line	:	91-902 FORT WEAVER RD STE 208
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-2261
Country	:	US
Telephone Number	:	808-689-7964
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LYLE T. TENJOMA
Credential	:	DDS, MSD
Telephone Number	:	808-941-4511

Provider Enumeration Date	:	06/09/2015
Last Update Date	:	06/09/2015

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