Provider Demographics
NPI:1457737272
Name:WAILUKU DENTISTS LLC
Entity Type:Organization
Organization Name:WAILUKU DENTISTS LLC
Other - Org Name:HAWAII DENTAL WAILUKU
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DULY AUTHORIZED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:NOLAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-242-4774
Mailing Address - Street 1:50 SOUTH BERETANIA ST
Mailing Address - Street 2:C-117B
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813
Mailing Address - Country:US
Mailing Address - Phone:808-242-4774
Mailing Address - Fax:
Practice Address - Street 1:1885 MAIN ST
Practice Address - Street 2:SUITE 208
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793
Practice Address - Country:US
Practice Address - Phone:808-242-4774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2545122300000X
HI10301223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty