Provider Demographics
NPI:1043503071
Name:SOUTH RAINIER DENTISTRY, PLLC
Entity Type:Organization
Organization Name:SOUTH RAINIER DENTISTRY, PLLC
Other - Org Name:SOUTH RAINIER DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER, MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAT
Authorized Official - Middle Name:KHOA
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:206-721-8730
Mailing Address - Street 1:8730 RAINIER AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-4927
Mailing Address - Country:US
Mailing Address - Phone:206-721-8730
Mailing Address - Fax:206-721-5947
Practice Address - Street 1:8730 RAINIER AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-4927
Practice Address - Country:US
Practice Address - Phone:206-721-8730
Practice Address - Fax:206-721-5947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE102871223G0001X
WADE103061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty