Provider Demographics
NPI:1356492003
Name:FAMILY DENTAL CLINIC, INC.
Entity Type:Organization
Organization Name:FAMILY DENTAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTISTRY
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:PORMENTO
Authorized Official - Last Name:ADORA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:808-847-1225
Mailing Address - Street 1:1210 DILLINGHAM BLVD
Mailing Address - Street 2:SUITE 12
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-4436
Mailing Address - Country:US
Mailing Address - Phone:808-847-1225
Mailing Address - Fax:808-847-1226
Practice Address - Street 1:1210 DILLINGHAM BLVD
Practice Address - Street 2:SUITE 12
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-4436
Practice Address - Country:US
Practice Address - Phone:808-847-1225
Practice Address - Fax:808-847-1226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT18821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI1882OtherHDS
HI859012OtherUNITED CONCORDIA CO.,INC.
HIK0206603OtherHMSA
HI07806601Medicaid
HI=========OtherSEARFARERS WELFARE PLAN
HI=========OtherDELTA USA DENTAL CLAIMS
HI=========OtherMETLIFE DENTAL
HI07806601Medicaid
HI=========OtherCIGNA
HIK0206603OtherHMSA
HI=========OtherAETNA US HEALTHCARE
HI859012OtherUNITED CONCORDIA CO.,INC.