Provider Demographics
NPI:1386745735
Name:GAETA, FRED C (MA DDS)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:C
Last Name:GAETA
Suffix:
Gender:M
Credentials:MA DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75-5706 HANAMA PL
Mailing Address - Street 2:SUITE 105A
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-1745
Mailing Address - Country:US
Mailing Address - Phone:808-329-3314
Mailing Address - Fax:808-329-1354
Practice Address - Street 1:75-5706 HANAMA PL
Practice Address - Street 2:SUITE 105A
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-1745
Practice Address - Country:US
Practice Address - Phone:808-329-3314
Practice Address - Fax:808-329-1354
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI11561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI1938OtherHDS
HIJ29007OtherHMSA