Provider Demographics
NPI:1083656359
Name:HUALALAI DENTAL SERVICES
Entity Type:Organization
Organization Name:HUALALAI DENTAL SERVICES
Other - Org Name:GENTLE DENTAL (KONA)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PC HOLDER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEIGHTON
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:209-476-4700
Mailing Address - Street 1:555 W BENJAMIN HOLT DR
Mailing Address - Street 2:BUILDING B
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-3839
Mailing Address - Country:US
Mailing Address - Phone:309-476-4700
Mailing Address - Fax:209-478-6430
Practice Address - Street 1:75-1028 HENRY ST
Practice Address - Street 2:SUITE 203
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-1693
Practice Address - Country:US
Practice Address - Phone:808-329-4425
Practice Address - Fax:808-329-0872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty