Provider Demographics
NPI:1205193786
Name:LILLY ROAD FAMILY DENTISTRY
Entity Type:Organization
Organization Name:LILLY ROAD FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:DOWNING
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-259-1984
Mailing Address - Street 1:220 LILLY RD NE STE B
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-6101
Mailing Address - Country:US
Mailing Address - Phone:360-459-9694
Mailing Address - Fax:
Practice Address - Street 1:220 LILLY RD NE STE B
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-6101
Practice Address - Country:US
Practice Address - Phone:360-459-9694
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-20
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000090671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty