Provider Demographics
NPI:1437405826
Name:GUSHIKEN, MAVIS KEIKO (RDH)
Entity Type:Individual
Prefix:
First Name:MAVIS
Middle Name:KEIKO
Last Name:GUSHIKEN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 63037
Mailing Address - Street 2:21ST DENTAL MCBH
Mailing Address - City:KANEOHE BAY
Mailing Address - State:HI
Mailing Address - Zip Code:96863
Mailing Address - Country:US
Mailing Address - Phone:808-257-3100
Mailing Address - Fax:
Practice Address - Street 1:21ST DENTAL MCBH
Practice Address - Street 2:UNITE 38450
Practice Address - City:KANEOHE BAY
Practice Address - State:HI
Practice Address - Zip Code:96863
Practice Address - Country:US
Practice Address - Phone:808-257-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-03
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDH-423124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
H00766377OtherDRIVERS LICENSE