Provider Demographics
NPI:1457545063
Name:HANNON, JEREMY MARK (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:MARK
Last Name:HANNON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45-1144 KAMEHAMEHA HWY STE #301
Mailing Address - Street 2:
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744
Mailing Address - Country:US
Mailing Address - Phone:808-230-8000
Mailing Address - Fax:
Practice Address - Street 1:45-1144 KAMEHAMEHA HWY STE #301
Practice Address - Street 2:
Practice Address - City:KANEOHE
Practice Address - State:HI
Practice Address - Zip Code:96744
Practice Address - Country:US
Practice Address - Phone:808-230-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT22971223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03388570Medicaid
HI696908Medicaid
HI696908Medicaid