Provider Demographics
NPI:1366822017
Name:DAVINCI DENTAL
Entity Type:Organization
Organization Name:DAVINCI DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BEAU
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-409-9999
Mailing Address - Street 1:909 112TH AVE NE STE P104
Mailing Address - Street 2:DAVINVI DENTAL
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-8589
Mailing Address - Country:US
Mailing Address - Phone:425-409-9999
Mailing Address - Fax:
Practice Address - Street 1:909 112TH AVE NE STE P104
Practice Address - Street 2:DAVINCI DENTAL
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-8589
Practice Address - Country:US
Practice Address - Phone:425-409-9999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60555911261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental