Provider Demographics
NPI:1225046386
Name:DAMERELL, J. MICKEY (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:J. MICKEY
Middle Name:
Last Name:DAMERELL
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 LOWER MAIN ST STE 107
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-2054
Mailing Address - Country:US
Mailing Address - Phone:808-244-1499
Mailing Address - Fax:808-244-9377
Practice Address - Street 1:1129 LOWER MAIN ST STE 107
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2054
Practice Address - Country:US
Practice Address - Phone:808-244-1499
Practice Address - Fax:808-244-9377
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI009351223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics