Provider Demographics
NPI:1558676767
Name:ISHIKAWA, BLAKE C (DDS)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:C
Last Name:ISHIKAWA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 S BERETANIA ST STE 480
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-1870
Mailing Address - Country:US
Mailing Address - Phone:808-597-1221
Mailing Address - Fax:
Practice Address - Street 1:1401 S BERETANIA ST STE 480
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-1870
Practice Address - Country:US
Practice Address - Phone:808-597-1221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-11
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT 2409122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist