Provider Demographics
NPI:1659432995
Name:ICHIMURA, DEREK H (DMD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:H
Last Name:ICHIMURA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98-1247 KAAHUMANU ST STE 215
Mailing Address - Street 2:
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-5310
Mailing Address - Country:US
Mailing Address - Phone:808-484-0529
Mailing Address - Fax:808-484-0629
Practice Address - Street 1:98-1247 KAAHUMANU ST STE 215
Practice Address - Street 2:
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-5310
Practice Address - Country:US
Practice Address - Phone:808-484-0529
Practice Address - Fax:808-484-0629
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT15571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice