Provider Demographics
NPI:1093909558
Name:THE DENTISTS CLINIC
Entity Type:Organization
Organization Name:THE DENTISTS CLINIC
Other - Org Name:ISA DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:671-646-7982
Mailing Address - Street 1:PO BOX W
Mailing Address - Street 2:
Mailing Address - City:HAGATNA
Mailing Address - State:GU
Mailing Address - Zip Code:96932
Mailing Address - Country:US
Mailing Address - Phone:671-646-7982
Mailing Address - Fax:671-646-7989
Practice Address - Street 1:761 S MARINE CORPS DRIVE
Practice Address - Street 2:SUITE A-2 CENTAM BUILDING
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913
Practice Address - Country:US
Practice Address - Phone:671-646-7982
Practice Address - Fax:671-646-7989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUD 8291223G0001X
GUD 9011223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI555029OtherHAWAII DENTAL SERVICES
GU185Medicaid