Provider Demographics
NPI:1295108280
Name:ISLAND DENTAL GROUP INC
Entity type:Organization
Organization Name:ISLAND DENTAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAUDE
Authorized Official - Middle Name:NOBORU
Authorized Official - Last Name:TAMURA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:808-484-4470
Mailing Address - Street 1:98-1247 KAAHUMANU ST
Mailing Address - Street 2:SUITE 214
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-5311
Mailing Address - Country:US
Mailing Address - Phone:808-484-4470
Mailing Address - Fax:808-484-4462
Practice Address - Street 1:98-1247 KAAHUMANU ST
Practice Address - Street 2:SUITE 214
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-5311
Practice Address - Country:US
Practice Address - Phone:808-484-4470
Practice Address - Fax:808-484-4462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BC3200X
HIDT 1744122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI7485240001Medicare NSC