Provider Demographics
NPI:1215372313
Name:KENT K KUSAKABE D.D.S., P.S.
Entity Type:Organization
Organization Name:KENT K KUSAKABE D.D.S., P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:KOSHI
Authorized Official - Last Name:KUSAKABE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:206-660-4488
Mailing Address - Street 1:8831 206TH ST SE APT B
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98296-5167
Mailing Address - Country:US
Mailing Address - Phone:206-660-4488
Mailing Address - Fax:
Practice Address - Street 1:8435 161ST AVE NE STE 2
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-1513
Practice Address - Country:US
Practice Address - Phone:206-660-4488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6032886371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5001813Medicaid