Provider Demographics
NPI:1316213374
Name:EVERGREEN FAMILY DENTISTRY, INC.
Entity Type:Organization
Organization Name:EVERGREEN FAMILY DENTISTRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MONSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-805-0211
Mailing Address - Street 1:17798 147TH ST SE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-1030
Mailing Address - Country:US
Mailing Address - Phone:360-805-0211
Mailing Address - Fax:360-863-9222
Practice Address - Street 1:17798 147TH ST SE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1030
Practice Address - Country:US
Practice Address - Phone:360-805-0211
Practice Address - Fax:360-863-9222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-23
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA7077332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies