Provider Demographics
NPI:1073986543
Name:WAILUKU DENTAL GROUP INC
Entity Type:Organization
Organization Name:WAILUKU DENTAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:LAU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:808-244-8808
Mailing Address - Street 1:255 IMI KALA ST
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-1282
Mailing Address - Country:US
Mailing Address - Phone:808-244-8808
Mailing Address - Fax:808-244-6032
Practice Address - Street 1:255 IMI KALA ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1282
Practice Address - Country:US
Practice Address - Phone:808-244-8808
Practice Address - Fax:808-244-6032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI13881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty