Basic Information
| Provider Information | |||||||||
| NPI: | 1356304000 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KAOPUA | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 KALANIANAOLE AVE | ||||||||
| Address2: | BAY CLINIC INC | ||||||||
| City: | HILO | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8089300419 | ||||||||
| FaxNumber: | 8089615167 | ||||||||
| Practice Location | |||||||||
| Address1: | 16-192 PILI MUA ST | ||||||||
| Address2: | KEAAU FAMILY HEALTH CENTER | ||||||||
| City: | KEAAU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8089300400 | ||||||||
| FaxNumber: | 8089343238 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 12/06/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DT2042 | HI | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 824916 | 01 | HI | UHA | OTHER | D217358 | 01 | HI | HMSA | OTHER | 252240 | 05 | HI | MEDICAID |