Provider Demographics
NPI:1275136814
Name:WALDRON, KEON
Entity Type:Individual
Prefix:MR
First Name:KEON
Middle Name:
Last Name:WALDRON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1522 KAMANU LN
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-6013
Mailing Address - Country:US
Mailing Address - Phone:973-780-0109
Mailing Address - Fax:
Practice Address - Street 1:BLDG. 6905 HARRIS ST.
Practice Address - Street 2:
Practice Address - City:KANEOHE
Practice Address - State:HI
Practice Address - Zip Code:96863
Practice Address - Country:US
Practice Address - Phone:808-473-0821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26901124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist