Provider Demographics
NPI:1497856694
Name:ODA, GARY T (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:T
Last Name:ODA
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 1:91-791 PAPIPI RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-2437
Mailing Address - Country:US
Mailing Address - Phone:808-689-7966
Mailing Address - Fax:808-689-0966
Practice Address - Street 1:91-791 PAPIPI RD
Practice Address - Street 2:SUITE 1
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-2437
Practice Address - Country:US
Practice Address - Phone:808-689-7966
Practice Address - Fax:808-689-0966
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI12811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI01371601Medicaid