Provider Demographics
NPI:1235177734
Name:EVERGREEN DENTAL CORPORATION
Entity Type:Organization
Organization Name:EVERGREEN DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:T.
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:DANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-385-3170
Mailing Address - Street 1:10315 19TH AVE SE
Mailing Address - Street 2:STE 102
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-4259
Mailing Address - Country:US
Mailing Address - Phone:425-385-3170
Mailing Address - Fax:425-385-3907
Practice Address - Street 1:10315 19TH AVE SE
Practice Address - Street 2:STE 102
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-4259
Practice Address - Country:US
Practice Address - Phone:425-385-3170
Practice Address - Fax:425-385-3907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty