MEDICARE: DR. CANDACE M. WADA D.D.S.

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	1223G0001X	General Practice Dentistry	1922	HI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1922	OTHER	HI	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1104830454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CANDACE M. WADA D.D.S.

Provider Business Mailing Address
First Line	:	4211 WAIALAE AVE
Second Line	:	SUITE 309
City	:	HONOLULU
State	:	HI
Zip	:	96816-5306
Country	:	US
Telephone Number	:	808-732-9232
Fax Number	:	808-739-2132

Provider Business Practice Location Address
First Line	:	4211 WAIALAE AVE
Second Line	:	SUITE 309
City	:	HONOLULU
State	:	HI
Zip	:	96816-5306
Country	:	US
Telephone Number	:	808-732-9232
Fax Number	:	808-739-2132

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2006
Last Update Date	:	07/08/2007

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