Provider Demographics
NPI:1962685511
Name:MAUI ORAL SURGERY LLC
Entity Type:Organization
Organization Name:MAUI ORAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:RASMUSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:808-244-7634
Mailing Address - Street 1:1063 L MAIN ST
Mailing Address - Street 2:STE C221
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793
Mailing Address - Country:US
Mailing Address - Phone:808-244-7634
Mailing Address - Fax:808-242-2851
Practice Address - Street 1:1063 L MAIN ST
Practice Address - Street 2:STE C221
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793
Practice Address - Country:US
Practice Address - Phone:808-244-7634
Practice Address - Fax:808-242-2851
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAUL ORAL SURGERY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-06
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT926122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty