Provider Demographics
NPI:1205412467
Name:PACIFIC NORTHWEST DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:PACIFIC NORTHWEST DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEVEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-995-0025
Mailing Address - Street 1:870 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2728 WESTMOOR CT SW STE D
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5779
Practice Address - Country:US
Practice Address - Phone:360-995-0025
Practice Address - Fax:360-995-0027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental