Provider Demographics
NPI:1841353547
Name:FASIG, KENNETH (DDS)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:FASIG
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:PO BOX 3990
Mailing Address - Street 2:
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766-6990
Mailing Address - Country:US
Mailing Address - Phone:808-240-0100
Mailing Address - Fax:808-245-8867
Practice Address - Street 1:4643B WAIMEA CANYON DRIVE
Practice Address - Street 2:
Practice Address - City:WAIMEA
Practice Address - State:HI
Practice Address - Zip Code:96796
Practice Address - Country:US
Practice Address - Phone:808-240-0150
Practice Address - Fax:808-338-9646
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HICSDT31223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI523979-02Medicaid
HICSDT3OtherHDS
HI0000252361OtherHMSA WEST