Provider Demographics
NPI:1316278906
Name:HAWAIIAN ISLAND DENTAL, INC.
Entity type:Organization
Organization Name:HAWAIIAN ISLAND DENTAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:P
Authorized Official - Last Name:JAUREQUI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:808-245-8866
Mailing Address - Street 1:4370 KUKUI GROVE ST
Mailing Address - Street 2:SUITE 211
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766-2001
Mailing Address - Country:US
Mailing Address - Phone:808-245-8866
Mailing Address - Fax:808-246-0698
Practice Address - Street 1:4370 KUKUI GROVE ST
Practice Address - Street 2:SUITE 211
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-2001
Practice Address - Country:US
Practice Address - Phone:808-245-8866
Practice Address - Fax:808-246-0698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-20
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIHI20091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty