Provider Demographics
NPI:1104162858
Name:ELITE SMILE CENTER, LLC
Entity type:Organization
Organization Name:ELITE SMILE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WON
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAEKAL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:808-329-4425
Mailing Address - Street 1:75-1028 HENRY ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-1693
Mailing Address - Country:US
Mailing Address - Phone:808-329-4425
Mailing Address - Fax:808-329-0872
Practice Address - Street 1:75-1028 HENRY ST
Practice Address - Street 2:SUITE 203
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-1693
Practice Address - Country:US
Practice Address - Phone:808-329-4425
Practice Address - Fax:808-329-0872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-28
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT-19041223G0001X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty