Provider Demographics
NPI:1346636263
Name:PHAM WALTER PLLC
Entity Type:Organization
Organization Name:PHAM WALTER PLLC
Other - Org Name:MUKILTEO DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LORIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MONIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-347-4141
Mailing Address - Street 1:7928 MUKILTEO SPEEDWAY STE 201
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-2607
Mailing Address - Country:US
Mailing Address - Phone:425-347-4141
Mailing Address - Fax:
Practice Address - Street 1:7928 MUKILTEO SPEEDWAY STE 201
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-2607
Practice Address - Country:US
Practice Address - Phone:425-347-4141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-07
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00008539122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty