Provider Demographics
NPI:1407172406
Name:NW FAMILY DENTAL
Entity Type:Organization
Organization Name:NW FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:NAKANISHI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, CDT
Authorized Official - Phone:425-883-2933
Mailing Address - Street 1:15955 NE 85TH ST
Mailing Address - Street 2:STE 101
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-3550
Mailing Address - Country:US
Mailing Address - Phone:425-883-2933
Mailing Address - Fax:425-885-0146
Practice Address - Street 1:15955 NE 85TH ST
Practice Address - Street 2:STE 101
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3550
Practice Address - Country:US
Practice Address - Phone:425-883-2933
Practice Address - Fax:425-885-0146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-15
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA603-005-0651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty