Provider Demographics
NPI:1083799068
Name:A STREET DENTAL CLINIC
Entity Type:Organization
Organization Name:A STREET DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:LEUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-288-9608
Mailing Address - Street 1:702 SW 294TH ST
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98023-3542
Mailing Address - Country:US
Mailing Address - Phone:253-288-9608
Mailing Address - Fax:253-288-9631
Practice Address - Street 1:902 A ST SE
Practice Address - Street 2:SUITE A
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-6056
Practice Address - Country:US
Practice Address - Phone:253-288-9608
Practice Address - Fax:253-288-9631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA98101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5040621Medicaid