Provider Demographics
NPI:1396019956
Name:PUKALANI DENTAL GROUP, LLP
Entity Type:Organization
Organization Name:PUKALANI DENTAL GROUP, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:OMURO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:808-572-9111
Mailing Address - Street 1:3434 OLD HALEAKALA HWY
Mailing Address - Street 2:
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768-8510
Mailing Address - Country:US
Mailing Address - Phone:808-572-9111
Mailing Address - Fax:
Practice Address - Street 1:3434 OLD HALEAKALA HWY
Practice Address - Street 2:
Practice Address - City:MAKAWAO
Practice Address - State:HI
Practice Address - Zip Code:96768-8510
Practice Address - Country:US
Practice Address - Phone:808-572-9111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-29
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1453122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty