Provider Demographics
NPI:1245265719
Name:KOUCHI, JEROLD T (DDS)
Entity type:Individual
Prefix:
First Name:JEROLD
Middle Name:T
Last Name:KOUCHI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1744 LILIHA ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-3115
Mailing Address - Country:US
Mailing Address - Phone:808-536-6073
Mailing Address - Fax:
Practice Address - Street 1:1744 LILIHA ST STE 207
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-3115
Practice Address - Country:US
Practice Address - Phone:808-536-6073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI17371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice