Provider Demographics
NPI:1962871483
Name:BLAKE ISHIKAWA, LLC
Entity type:Organization
Organization Name:BLAKE ISHIKAWA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENDODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:C
Authorized Official - Last Name:ISHIKAWA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:808-561-0955
Mailing Address - Street 1:3566 TROUSSEAU ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96815-4353
Mailing Address - Country:US
Mailing Address - Phone:808-561-0955
Mailing Address - Fax:
Practice Address - Street 1:410 KILANI AVE
Practice Address - Street 2:#221
Practice Address - City:WAHIAWA
Practice Address - State:HI
Practice Address - Zip Code:96786-1844
Practice Address - Country:US
Practice Address - Phone:808-622-4354
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT24091223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty