Provider Demographics
NPI:1457724940
Name:12TH AVENUE DENTAL CENTRE, LLC
Entity Type:Organization
Organization Name:12TH AVENUE DENTAL CENTRE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYASHI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:808-737-3311
Mailing Address - Street 1:1144 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-3712
Mailing Address - Country:US
Mailing Address - Phone:808-737-3311
Mailing Address - Fax:
Practice Address - Street 1:1144 12TH AVE
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-3712
Practice Address - Country:US
Practice Address - Phone:808-737-3311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1514122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty