Provider Demographics
NPI:1689358160
Name:TOM, CLARICE KAEKO
Entity Type:Individual
Prefix:MRS
First Name:CLARICE
Middle Name:KAEKO
Last Name:TOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 AHUAWA LOOP
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-5601
Mailing Address - Country:US
Mailing Address - Phone:808-391-3765
Mailing Address - Fax:
Practice Address - Street 1:41-1347 KALANIANAOLE HWY STE A
Practice Address - Street 2:
Practice Address - City:WAIMANALO
Practice Address - State:HI
Practice Address - Zip Code:96795-1297
Practice Address - Country:US
Practice Address - Phone:808-259-5466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDH1151124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist