Provider Demographics
NPI:1407291537
Name:LAKE BELLEVUE DENTAL CARE, INC
Entity Type:Organization
Organization Name:LAKE BELLEVUE DENTAL CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-453-2030
Mailing Address - Street 1:1 LAKE BELLEVUE DR STE 108
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-2417
Mailing Address - Country:US
Mailing Address - Phone:425-453-2030
Mailing Address - Fax:425-505-2382
Practice Address - Street 1:1 LAKE BELLEVUE DR STE 108
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-2417
Practice Address - Country:US
Practice Address - Phone:425-453-2030
Practice Address - Fax:425-505-2382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE600148121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty