Basic Information
Provider Information
NPI: 1851676746
EntityType: 2
ReplacementNPI:  
OrganizationName: BAY CLINIC INC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: HILO FAMILY DENTAL CENTER
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 450 KILAUEA AVE
Address2: STE 105
City: HILO
State: HI
PostalCode: 967203089
CountryCode: US
TelephoneNumber: 8089614071
FaxNumber: 8089615678
Practice Location
Address1: 1257 KILAUEA AVE
Address2: SUITE 100
City: HILO
State: HI
PostalCode: 967204205
CountryCode: US
TelephoneNumber: 8083333600
FaxNumber: 8089615678
Other Information
ProviderEnumerationDate: 10/11/2011
LastUpdateDate: 11/11/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: ALAMEDA
AuthorizedOfficialFirstName: CHRISTIAN
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CEO
AuthorizedOfficialTelephone: 8089614083
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 11/11/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X  N193200000X MULTI-SPECIALTY GROUPDental ProvidersDentist 
261QF0400X  Y Ambulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)

ID Information
IDTypeStateIssuerDescription
69673405HI MEDICAID


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