Provider Demographics
NPI:1407126873
Name:PACIFIC CHILDRENS DENTISTRY
Entity Type:Organization
Organization Name:PACIFIC CHILDRENS DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TARJA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAAKKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-355-1596
Mailing Address - Street 1:700 NW GILMAN BLVD
Mailing Address - Street 2:E-103, #493
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-5395
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:916 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4147
Practice Address - Country:US
Practice Address - Phone:206-355-1596
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA93971223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1306911383OtherPERSONAL NPI 1306911383
WA5056239Medicaid