Basic Information
| Provider Information | |||||||||
| NPI: | 1386903631 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANTORI | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | LENORE | ||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCBURNETT | ||||||||
| OtherFirstName: | HEATHER | ||||||||
| OtherMiddleName: | LENORE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 224 HAILI ST | ||||||||
| Address2: | BLDG B | ||||||||
| City: | HILO | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967202975 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 16-192 PILI MUA ST | ||||||||
| Address2: | |||||||||
| City: | KEAAU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967498134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8089300400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2012 | ||||||||
| LastUpdateDate: | 03/24/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1223D0001X | 195 | HI | N | Dental Providers | Dentist | Dental Public Health | 122300000X | 2504 | HI | Y | Dental Providers | Dentist |
No ID Information.