Provider Demographics
NPI:1033328646
Name:PACIFIC FAMILY DENTAL, INC.
Entity Type:Organization
Organization Name:PACIFIC FAMILY DENTAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:KEKOA
Authorized Official - Last Name:WATANABE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:808-422-1155
Mailing Address - Street 1:4429 MALAAI ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96818-3158
Mailing Address - Country:US
Mailing Address - Phone:808-422-1155
Mailing Address - Fax:
Practice Address - Street 1:4429 MALAAI ST
Practice Address - Street 2:SUITE 103
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96818-3158
Practice Address - Country:US
Practice Address - Phone:808-422-1155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT1923261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental