Provider Demographics
NPI:1164740445
Name:NORTHWEST DENTURE CENTERS
Entity Type:Organization
Organization Name:NORTHWEST DENTURE CENTERS
Other - Org Name:NORTHWEST DENTAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:J
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LD
Authorized Official - Phone:360-676-1499
Mailing Address - Street 1:2710 MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-2411
Mailing Address - Country:US
Mailing Address - Phone:360-676-1499
Mailing Address - Fax:360-738-2281
Practice Address - Street 1:2710 MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-2411
Practice Address - Country:US
Practice Address - Phone:360-676-1499
Practice Address - Fax:360-738-2281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-11
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN0000002122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5041850Medicaid