Provider Demographics
NPI:1073763041
Name:ELEVEN ELEVEN DENTAL
Entity Type:Organization
Organization Name:ELEVEN ELEVEN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BIRCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-457-3183
Mailing Address - Street 1:1111 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-4207
Mailing Address - Country:US
Mailing Address - Phone:360-457-3183
Mailing Address - Fax:
Practice Address - Street 1:1111 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-4207
Practice Address - Country:US
Practice Address - Phone:360-457-3183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-25
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602789281261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental