Provider Demographics
NPI:1316010531
Name:JAY D. DEIGLMEIER DDS. PS
Entity Type:Organization
Organization Name:JAY D. DEIGLMEIER DDS. PS
Other - Org Name:PANTHER LAKE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEIGLMEIER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-854-1222
Mailing Address - Street 1:10920 SE 208TH ST
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98031-4009
Mailing Address - Country:US
Mailing Address - Phone:253-854-1222
Mailing Address - Fax:
Practice Address - Street 1:10920 SE 208TH ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98031-4009
Practice Address - Country:US
Practice Address - Phone:253-854-1222
Practice Address - Fax:253-859-1269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000070641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADE7654OtherREGENCE
WA5025788Medicaid
WA103746OtherL & I
WA57064OtherWDS
WA5023221Medicaid