Basic Information
| Provider Information | |||||||||
| NPI: | 1811490550 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WASHINGTON DENTAL CORPORATION PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LAKE STEVENS MODERN DENTISTRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17000 RED HILL AVE | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926145626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148458500 | ||||||||
| FaxNumber: | 3039520892 | ||||||||
| Practice Location | |||||||||
| Address1: | 907 FRONTIER CIRCLE E | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | LAKE STEVENS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256979219 | ||||||||
| FaxNumber: | 4256979228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2018 | ||||||||
| LastUpdateDate: | 03/08/2018 | ||||||||
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| AuthorizedOfficialLastName: | GOMEZ | ||||||||
| AuthorizedOfficialFirstName: | DULCE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7148458701 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.