Basic Information
| Provider Information | |||||||||
| NPI: | 1245643667 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAKEMOTO | ||||||||
| FirstName: | MARY JANE | ||||||||
| MiddleName: | D.R. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TUVERA-TALEMOTO | ||||||||
| OtherFirstName: | MARY JANE | ||||||||
| OtherMiddleName: | D.R. | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | R.D.H. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4323 LAAKEA ST | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968181966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084224420 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1253 MAKALAPA GATE RD | ||||||||
| Address2: | |||||||||
| City: | JBPHH | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968604479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084731880 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2014 | ||||||||
| LastUpdateDate: | 06/03/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | DH-1027 | HI | Y | Dental Providers | Dental Hygienist |
No ID Information.