Provider Demographics
NPI:1316774177
Name:KAILUA FAMILY DENTAL LLC
Entity type:Organization
Organization Name:KAILUA FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LEON
Authorized Official - Middle Name:AJAYI
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:650-302-7086
Mailing Address - Street 1:1379 MANU ALOHA ST
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-4375
Mailing Address - Country:US
Mailing Address - Phone:650-302-7086
Mailing Address - Fax:
Practice Address - Street 1:407 ULUNIU ST STE 114
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-2531
Practice Address - Country:US
Practice Address - Phone:808-261-5951
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-16
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental