Provider Demographics
NPI:1164585634
Name:SOUTH SOUND FAMILY DENTISTRY, PLLC
Entity Type:Organization
Organization Name:SOUTH SOUND FAMILY DENTISTRY, PLLC
Other - Org Name:SOUTH SOUND FAMILY DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEVI
Authorized Official - Middle Name:G
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-459-3400
Mailing Address - Street 1:703 LILLY RD NE STE 201
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5256
Mailing Address - Country:US
Mailing Address - Phone:360-459-3400
Mailing Address - Fax:
Practice Address - Street 1:703 LILLY RD NE STE 201
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5256
Practice Address - Country:US
Practice Address - Phone:360-459-3400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000099861223G0001X
WA99861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0215386OtherL & I GROUP PROVIDER #