Provider Demographics
NPI:1770256448
Name:SAN DIEGO, ERIC SCOTT KANEMOKUHEALII (DMD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:SCOTT KANEMOKUHEALII
Last Name:SAN DIEGO
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 1:980 BIRMINGHAM RD STE 507
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:GA
Mailing Address - Zip Code:30004-4418
Mailing Address - Country:US
Mailing Address - Phone:678-352-1033
Mailing Address - Fax:
Practice Address - Street 1:980 BIRMINGHAM RD STE 507
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:GA
Practice Address - Zip Code:30004-4418
Practice Address - Country:US
Practice Address - Phone:678-352-1033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1222801223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty