Provider Demographics
NPI:1023132487
Name:TAN, IMELDA CELESTIAL (DMD)
Entity type:Individual
Prefix:DR
First Name:IMELDA
Middle Name:CELESTIAL
Last Name:TAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 LILIHA ST
Mailing Address - Street 2:SUITE 503
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-3562
Mailing Address - Country:US
Mailing Address - Phone:808-532-5888
Mailing Address - Fax:808-528-3384
Practice Address - Street 1:1520 LILIHA ST
Practice Address - Street 2:SUITE 503
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-3562
Practice Address - Country:US
Practice Address - Phone:808-532-5888
Practice Address - Fax:808-528-3384
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT 20881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIC24937-9OtherHMSA
HI208803OtherHDS
HI58234702Medicaid