Provider Demographics
NPI:1053351304
Name:VALDERUEDA, LISA MAE (DMD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:MAE
Last Name:VALDERUEDA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94-229 WAIPAHU DEPOT ST.
Mailing Address - Street 2:SUITE 500
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-3035
Mailing Address - Country:US
Mailing Address - Phone:808-676-5711
Mailing Address - Fax:808-671-4785
Practice Address - Street 1:94-229 WAIPAHU DEPOT ST.
Practice Address - Street 2:SUITE 500
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-3035
Practice Address - Country:US
Practice Address - Phone:808-676-5711
Practice Address - Fax:808-671-4785
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI15251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI025849-01Medicaid