Provider Demographics
NPI:1154631117
Name:WASHINGTON DENTAL SERVICE
Entity Type:Organization
Organization Name:WASHINGTON DENTAL SERVICE
Other - Org Name:SMILEMOBILE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:206-528-2335
Mailing Address - Street 1:9706 4TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-2157
Mailing Address - Country:US
Mailing Address - Phone:206-528-2337
Mailing Address - Fax:206-985-4950
Practice Address - Street 1:9706 4TH AVE NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-2157
Practice Address - Country:US
Practice Address - Phone:206-528-2337
Practice Address - Fax:206-985-4950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-08
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000054741223G0001X
WADE000052521223G0001X
WADE000067001223G0001X
WADE000052221223G0001X
WADE000044851223G0001X
WADE000057721223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty