Provider Demographics
NPI:1093427643
Name:KANEOHE KIDS DENTAL LLC
Entity Type:Organization
Organization Name:KANEOHE KIDS DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:YIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:808-341-9932
Mailing Address - Street 1:46-005 KAWA ST STE 301
Mailing Address - Street 2:
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744-3813
Mailing Address - Country:US
Mailing Address - Phone:808-235-0550
Mailing Address - Fax:808-234-1166
Practice Address - Street 1:46-005 KAWA ST STE 301
Practice Address - Street 2:
Practice Address - City:KANEOHE
Practice Address - State:HI
Practice Address - Zip Code:96744-3813
Practice Address - Country:US
Practice Address - Phone:808-235-0550
Practice Address - Fax:808-234-1166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI80292701Medicaid