Provider Demographics
NPI:1790121739
Name:SALT LAKE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:SALT LAKE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:TAMANAHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-839-7209
Mailing Address - Street 1:848 ALA LILIKOI ST STE 112
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96818-2109
Mailing Address - Country:US
Mailing Address - Phone:808-839-7209
Mailing Address - Fax:808-836-7700
Practice Address - Street 1:848 ALA LILIKOI ST STE 112
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96818-2109
Practice Address - Country:US
Practice Address - Phone:808-839-7209
Practice Address - Fax:808-836-7700
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SALT LAKE FAMILY DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-05-16
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT19441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty