Provider Demographics
NPI:1285785824
Name:TAKATA DENTAL HEALTH CENTER, INC.
Entity type:Organization
Organization Name:TAKATA DENTAL HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELLSWORTH
Authorized Official - Middle Name:H
Authorized Official - Last Name:TAKATA
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:808-935-3351
Mailing Address - Street 1:445 WAIANUENUE AVE
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-2535
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:445 WAIANUENUE AVE
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2535
Practice Address - Country:US
Practice Address - Phone:808-935-3351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI20681223G0001X
HI9911223G0001X
HI7511223P0221X
HI21021223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Not Answered1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI51866501Medicaid