Provider Demographics
NPI:1932675212
Name:DEPT. OF HEALTH-HI DEVELOPMENTAL DISABILITIES H&CDSB (DENTAL)
Entity Type:Organization
Organization Name:DEPT. OF HEALTH-HI DEVELOPMENTAL DISABILITIES H&CDSB (DENTAL)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDD ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-586-5842
Mailing Address - Street 1:1250 PUNCHBOWL ST STE 463
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2416
Mailing Address - Country:US
Mailing Address - Phone:808-586-5842
Mailing Address - Fax:808-586-5844
Practice Address - Street 1:1700 LANAKILA AVE RM 203
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-2115
Practice Address - Country:US
Practice Address - Phone:808-832-5710
Practice Address - Fax:808-832-5722
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF HAWAII, DEPARTMENT OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
No126800000XDental ProvidersDental AssistantGroup - Single Specialty