Provider Demographics
NPI:1710199054
Name:EMERALD ISLAND ORAL FACIAL SURGERY, INC.
Entity Type:Organization
Organization Name:EMERALD ISLAND ORAL FACIAL SURGERY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:808-245-9339
Mailing Address - Street 1:4414 KUKUI GROVE ST
Mailing Address - Street 2:SUITE #103
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766-2016
Mailing Address - Country:US
Mailing Address - Phone:808-245-9339
Mailing Address - Fax:
Practice Address - Street 1:4414 KUKUI GROVE ST
Practice Address - Street 2:SUITE #103
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-2016
Practice Address - Country:US
Practice Address - Phone:808-245-9339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT18861223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty