Provider Demographics
NPI:1194223537
Name:KITSAP DENTAL
Entity Type:Organization
Organization Name:KITSAP DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:LOIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-779-2420
Mailing Address - Street 1:20730 BOND RD NE STE 100
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-9000
Mailing Address - Country:US
Mailing Address - Phone:360-779-2420
Mailing Address - Fax:360-779-6219
Practice Address - Street 1:20730 BOND RD NE STE 100
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-9000
Practice Address - Country:US
Practice Address - Phone:360-779-2420
Practice Address - Fax:360-779-6219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-31
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60080602261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60080602OtherLICENSE NUMBER