Provider Demographics
NPI:1376918342
Name:INNOVATIVE ENDODONTIC SOLUTIONS
Entity Type:Organization
Organization Name:INNOVATIVE ENDODONTIC SOLUTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENDODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:REBECCA
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:206-930-8789
Mailing Address - Street 1:PO BOX 1180
Mailing Address - Street 2:
Mailing Address - City:DUVALL
Mailing Address - State:WA
Mailing Address - Zip Code:98019-1180
Mailing Address - Country:US
Mailing Address - Phone:425-788-9575
Mailing Address - Fax:425-788-9577
Practice Address - Street 1:26504 NE VALLEY STREET
Practice Address - Street 2:
Practice Address - City:DUVALL
Practice Address - State:WA
Practice Address - Zip Code:98019
Practice Address - Country:US
Practice Address - Phone:425-788-9575
Practice Address - Fax:425-788-9577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE605669001223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty