Provider Demographics
NPI:1174840896
Name:EVERETT DENTURE CENTER PLLC
Entity Type:Organization
Organization Name:EVERETT DENTURE CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:CHESLIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-259-2800
Mailing Address - Street 1:4367 RUCKER AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-2213
Mailing Address - Country:US
Mailing Address - Phone:425-259-2800
Mailing Address - Fax:425-259-2800
Practice Address - Street 1:4367 RUCKER AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-2213
Practice Address - Country:US
Practice Address - Phone:425-259-2800
Practice Address - Fax:425-259-2800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-21
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000342122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5049812Medicaid