Provider Demographics
NPI:1275996191
Name:SOUTH CENTER PEDIATRIC DENTISTRY AND ORTHODONTICS LLC
Entity Type:Organization
Organization Name:SOUTH CENTER PEDIATRIC DENTISTRY AND ORTHODONTICS LLC
Other - Org Name:SOUTH CENTER PEDIATRIC DENTISTRY AND ORTHODONTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHADEEP
Authorized Official - Middle Name:S
Authorized Official - Last Name:VIRK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:206-575-2556
Mailing Address - Street 1:505 STRANDER BLVD
Mailing Address - Street 2:
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98188-2920
Mailing Address - Country:US
Mailing Address - Phone:206-575-2556
Mailing Address - Fax:253-604-0598
Practice Address - Street 1:505 STRANDER BLVD
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-2920
Practice Address - Country:US
Practice Address - Phone:206-575-2556
Practice Address - Fax:253-604-0598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6035913811223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2010685Medicaid