Provider Demographics
NPI:1366591257
Name:WAKANO, CORY K (DDS)
Entity type:Individual
Prefix:DR
First Name:CORY
Middle Name:K
Last Name:WAKANO
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 1:120 PAUAHI ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-3067
Mailing Address - Country:US
Mailing Address - Phone:808-961-5617
Mailing Address - Fax:808-935-3290
Practice Address - Street 1:120 PAUAHI ST
Practice Address - Street 2:SUITE 204
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-3067
Practice Address - Country:US
Practice Address - Phone:808-961-5617
Practice Address - Fax:808-935-3290
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT-17961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI1796OtherHDS
HI24540901Medicaid
HIA9256-7OtherHMSA