Provider Demographics
NPI:1285615831
Name:OKUMOTO, GLENN M (DDS)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:M
Last Name:OKUMOTO
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 1:94309 WAIMAKA ST
Mailing Address - Street 2:
Mailing Address - City:MILLANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789
Mailing Address - Country:US
Mailing Address - Phone:808-625-7062
Mailing Address - Fax:808-832-5722
Practice Address - Street 1:1700 LANAKILA AVE
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817
Practice Address - Country:US
Practice Address - Phone:808-832-5710
Practice Address - Fax:808-832-5722
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI10241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI06784701Medicaid