Provider Demographics
NPI:1003228982
Name:WAIKOLOA DENTAL CLINIC INC
Entity Type:Organization
Organization Name:WAIKOLOA DENTAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:G
Authorized Official - Last Name:FOSTVEDT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:808-886-0891
Mailing Address - Street 1:69-201 WAIKOLOA BEACH DRIVE # 2615
Mailing Address - Street 2:
Mailing Address - City:WAIKOLOA
Mailing Address - State:HI
Mailing Address - Zip Code:96738
Mailing Address - Country:US
Mailing Address - Phone:808-886-0891
Mailing Address - Fax:808-886-0892
Practice Address - Street 1:69-201 WAIKOLOA BEACH DR STE 2615
Practice Address - Street 2:
Practice Address - City:WAIKOLOA
Practice Address - State:HI
Practice Address - Zip Code:96738-5815
Practice Address - Country:US
Practice Address - Phone:808-886-0891
Practice Address - Fax:808-886-0892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-27
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT 16061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty