MEDICARE: ALOHA STADIUM DENTAL ASSOCIATES

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	170400A0078749	HI

General Provider Information

NPI Number	:	1528484334
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALOHA STADIUM DENTAL ASSOCIATES

Provider Business Mailing Address
First Line	:	4510 SALT LAKE BLVD
Second Line	:	SUITE B-3
City	:	HONOLULU
State	:	HI
Zip	:	96818-3153
Country	:	US
Telephone Number	:	808-487-9948
Fax Number	:

Provider Business Practice Location Address
First Line	:	4510 SALT LAKE BLVD
Second Line	:	SUITE B-3
City	:	HONOLULU
State	:	HI
Zip	:	96818-3153
Country	:	US
Telephone Number	:	808-487-9948
Fax Number	:

Authorized Official
Title or Position	:	DOCTOR
Name	:	DR. TINA TOM
Credential	:
Telephone Number	:	808-487-9948

Provider Enumeration Date	:	03/17/2014
Last Update Date	:	05/22/2014

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