Provider Demographics
NPI:1356304000
Name:KAOPUA, JASON (DMD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:KAOPUA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 KALANIANAOLE AVE
Mailing Address - Street 2:BAY CLINIC INC
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720
Mailing Address - Country:US
Mailing Address - Phone:808-930-0419
Mailing Address - Fax:808-961-5167
Practice Address - Street 1:16-192 PILI MUA ST
Practice Address - Street 2:KEAAU FAMILY HEALTH CENTER
Practice Address - City:KEAAU
Practice Address - State:HI
Practice Address - Zip Code:96749
Practice Address - Country:US
Practice Address - Phone:808-930-0400
Practice Address - Fax:808-934-3238
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT2042122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI824916OtherUHA
HID217358OtherHMSA
HI252240Medicaid
U96282Medicare UPIN
HI252240Medicaid