Provider Demographics
NPI:1093374696
Name:ISLAND ORAL AND MAXILLOFACIAL SURGERY, L.L.C.
Entity Type:Organization
Organization Name:ISLAND ORAL AND MAXILLOFACIAL SURGERY, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:ABRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:808-674-2255
Mailing Address - Street 1:338 KAMOKILA BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-2055
Mailing Address - Country:US
Mailing Address - Phone:808-674-2255
Mailing Address - Fax:808-674-1771
Practice Address - Street 1:338 KAMOKILA BLVD STE 203
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-2055
Practice Address - Country:US
Practice Address - Phone:808-674-2255
Practice Address - Fax:808-674-1771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI629694Medicaid