Provider Demographics
NPI:1174826937
Name:KELLEY M. WASHINGTON DDS,PS
Entity Type:Organization
Organization Name:KELLEY M. WASHINGTON DDS,PS
Other - Org Name:WASHINGTON DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:206-722-8211
Mailing Address - Street 1:4543 RAINIER AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-1656
Mailing Address - Country:US
Mailing Address - Phone:206-722-8211
Mailing Address - Fax:206-722-3249
Practice Address - Street 1:4543 RAINIER AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-1656
Practice Address - Country:US
Practice Address - Phone:206-722-8211
Practice Address - Fax:206-722-3249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA9721261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental