Provider Demographics
NPI:1669826244
Name:DEREK B TOM DDS LLC
Entity Type:Organization
Organization Name:DEREK B TOM DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:B
Authorized Official - Last Name:TOM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:808-488-0100
Mailing Address - Street 1:98-150 KAONOHI ST
Mailing Address - Street 2:C207
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-5047
Mailing Address - Country:US
Mailing Address - Phone:808-488-0100
Mailing Address - Fax:808-488-0110
Practice Address - Street 1:98-150 KAONOHI ST
Practice Address - Street 2:C207
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-5047
Practice Address - Country:US
Practice Address - Phone:808-488-0100
Practice Address - Fax:808-488-0110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT-20081223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty