Provider Demographics
NPI:1891235560
Name:ANCHETA PEDIATRIC DENTAL LLC
Entity Type:Organization
Organization Name:ANCHETA PEDIATRIC DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JANEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ANCHETA-CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:808-561-2054
Mailing Address - Street 1:98-1247 KAAHUMANU ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-5311
Mailing Address - Country:US
Mailing Address - Phone:808-487-1009
Mailing Address - Fax:808-487-1004
Practice Address - Street 1:98-1247 KAAHUMANU ST
Practice Address - Street 2:SUITE 205
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-5311
Practice Address - Country:US
Practice Address - Phone:808-487-1009
Practice Address - Fax:808-487-1004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT-2079261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI574857-03Medicaid