Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 12671 | CT |
Y | 1223E0200X | Endodontist | DT-2895 | HI |
NPI | 1124648910 |
---|---|
Provider Name | Phianh Waldon |
First Address | Honolulu, HI 96813-2807 |
Second Address | Honolulu, HI 96814-1879 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/04/2020 |
Last Update Date | 29/10/2021 |