Provider Demographics
NPI:1306225511
Name:KIRKLAND KIDS DENTISTRY
Entity Type:Organization
Organization Name:KIRKLAND KIDS DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ALLYSON
Authorized Official - Middle Name:STEWART
Authorized Official - Last Name:DKEIDEK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS CERT
Authorized Official - Phone:716-725-4676
Mailing Address - Street 1:13118 121ST WAY NE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-3004
Mailing Address - Country:US
Mailing Address - Phone:716-725-4676
Mailing Address - Fax:
Practice Address - Street 1:13118 121ST WAY NE
Practice Address - Street 2:SUITE 103
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3004
Practice Address - Country:US
Practice Address - Phone:716-725-4676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601242991223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2008604Medicaid