Basic Information
| Provider Information | |||||||||
| NPI: | 1649460288 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHC OF SNOHOMISH COUNTY 112TH DENTAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13060 | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982063060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257893700 | ||||||||
| FaxNumber: | 4257893754 | ||||||||
| Practice Location | |||||||||
| Address1: | 1019 112TH ST SW | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255516001 | ||||||||
| FaxNumber: | 4255516008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2007 | ||||||||
| LastUpdateDate: | 07/30/2007 | ||||||||
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| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4257893700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 5010921 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 5010921 | 05 | WA | MEDICAID |