Provider Demographics
NPI:1487885166
Name:HAWAII DENTAL IMPLANT CENTER LLC
Entity type:Organization
Organization Name:HAWAII DENTAL IMPLANT CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JMI
Authorized Official - Middle Name:L
Authorized Official - Last Name:ASAM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:808-781-9964
Mailing Address - Street 1:4211 WAIALAE AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-5319
Mailing Address - Country:US
Mailing Address - Phone:808-737-6150
Mailing Address - Fax:
Practice Address - Street 1:4211 WAIALAE AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-5319
Practice Address - Country:US
Practice Address - Phone:808-737-6150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-29
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT-2153122300000X, 1223P0700X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty