Basic Information
| Provider Information | |||||||||
| NPI: | 1184155400 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | SPENCER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 642 ULUKAHIKI ST STE 308 | ||||||||
| Address2: | |||||||||
| City: | KAILUA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967344439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8083842707 | ||||||||
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| Practice Location | |||||||||
| Address1: | 642 ULUKAHIKI ST STE 308 | ||||||||
| Address2: | |||||||||
| City: | KAILUA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967344439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082615354 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2017 | ||||||||
| LastUpdateDate: | 07/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1223P0221X | DT-2748 | HI | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.