Provider Demographics
NPI:1528548716
Name:LISA VALDERUEDA, DMD, INC.
Entity Type:Organization
Organization Name:LISA VALDERUEDA, DMD, INC.
Other - Org Name:LISA VALDERUEDA, DMD, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:VALDERUEDA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:808-676-5711
Mailing Address - Street 1:94-229 WAIPAHU DEPOT ST STE 500
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-3035
Mailing Address - Country:US
Mailing Address - Phone:808-676-5711
Mailing Address - Fax:808-671-4785
Practice Address - Street 1:94-229 WAIPAHU DEPOT ST STE 500
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-3035
Practice Address - Country:US
Practice Address - Phone:808-676-5711
Practice Address - Fax:808-671-4785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1525261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental