Provider Demographics
NPI:1720606965
Name:FUKADA, KEILEEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEILEEN
Middle Name:
Last Name:FUKADA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95-102 MAHOA PL
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-3025
Mailing Address - Country:US
Mailing Address - Phone:808-347-3899
Mailing Address - Fax:
Practice Address - Street 1:98-211 PALI MOMI ST STE 737
Practice Address - Street 2:
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-4339
Practice Address - Country:US
Practice Address - Phone:808-487-1554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT-2859122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist