Provider Demographics
NPI:1336289982
Name:AULT, GARY LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:AULT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81-990 HALEKII ST STE 7
Mailing Address - Street 2:
Mailing Address - City:KEALAKEKUA
Mailing Address - State:HI
Mailing Address - Zip Code:96750-8104
Mailing Address - Country:US
Mailing Address - Phone:808-322-9355
Mailing Address - Fax:808-322-6130
Practice Address - Street 1:81-990 HALEKII ST STE 7
Practice Address - Street 2:
Practice Address - City:KEALAKEKUA
Practice Address - State:HI
Practice Address - Zip Code:96750-8104
Practice Address - Country:US
Practice Address - Phone:808-322-9355
Practice Address - Fax:808-322-6130
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI17501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000597201Medicaid