Provider Demographics
NPI:1205209913
Name:THE MILL CREEK DENTIST
Entity Type:Organization
Organization Name:THE MILL CREEK DENTIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-745-4661
Mailing Address - Street 1:16306 BOTHELL EVERETT HWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-1283
Mailing Address - Country:US
Mailing Address - Phone:425-745-4661
Mailing Address - Fax:425-491-7077
Practice Address - Street 1:16306 BOTHELL EVERETT HWY
Practice Address - Street 2:SUITE B
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-1283
Practice Address - Country:US
Practice Address - Phone:425-745-4661
Practice Address - Fax:425-491-7077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000053391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty