Provider Demographics
NPI:1154675064
Name:PSPD - LAKE STEVENS PLLC
Entity Type:Organization
Organization Name:PSPD - LAKE STEVENS PLLC
Other - Org Name:PUGET SOUND PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACCOUNT RECEIVABLE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:R
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-367-4149
Mailing Address - Street 1:9421 N. DAVIES ROAD #A
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258
Mailing Address - Country:US
Mailing Address - Phone:425-367-4149
Mailing Address - Fax:425-609-4530
Practice Address - Street 1:9421 N. DAVIES ROAD #A
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258
Practice Address - Country:US
Practice Address - Phone:425-367-4149
Practice Address - Fax:425-609-4530
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LUGO DMD MARYSVILLE PS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-30
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000099181223P0221X
1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty