Provider Demographics
NPI:1134247414
Name:ISLAND DENTISTRY, INC.
Entity type:Organization
Organization Name:ISLAND DENTISTRY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LILLY
Authorized Official - Middle Name:LI
Authorized Official - Last Name:GEYER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:808-384-4579
Mailing Address - Street 1:30 AULIKE ST
Mailing Address - Street 2:SUITE 503
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-2707
Mailing Address - Country:US
Mailing Address - Phone:808-384-4579
Mailing Address - Fax:808-261-1449
Practice Address - Street 1:30 AULIKE ST
Practice Address - Street 2:SUITE 503
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-2707
Practice Address - Country:US
Practice Address - Phone:808-384-4579
Practice Address - Fax:808-261-1449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT21061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI575441-04Medicaid