Provider Demographics
NPI:1407395668
Name:PREMIER DENTAL GROUP HI INC
Entity type:Organization
Organization Name:PREMIER DENTAL GROUP HI INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:Y
Authorized Official - Last Name:TAKAKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:808-487-1554
Mailing Address - Street 1:98-211 PALI MOMI ST
Mailing Address - Street 2:SUITE 737
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-4301
Mailing Address - Country:US
Mailing Address - Phone:808-342-8611
Mailing Address - Fax:808-487-1556
Practice Address - Street 1:98-211 PALI MOMI ST
Practice Address - Street 2:SUITE 737
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-4301
Practice Address - Country:US
Practice Address - Phone:808-342-8611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT21071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty