1083656359 NPI number — HUALALAI DENTAL SERVICES

Table of content: (NPI 1083656359)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083656359 NPI number — HUALALAI DENTAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HUALALAI DENTAL SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083656359
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 W BENJAMIN HOLT DR
Provider Second Line Business Mailing Address:
BUILDING B
Provider Business Mailing Address City Name:
STOCKTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95207-3839
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-476-4700
Provider Business Mailing Address Fax Number:
209-478-6430

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75-1028 HENRY ST
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
KAILUA KONA
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96740-1693
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-329-4425
Provider Business Practice Location Address Fax Number:
808-329-0872
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
LEIGHTON
Authorized Official Middle Name:
THOMAS
Authorized Official Title or Position:
PC HOLDER
Authorized Official Telephone Number:
209-476-4700

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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