Provider Demographics
NPI:1407574791
Name:PACIFIC TELEDENTISTRY
Entity Type:Organization
Organization Name:PACIFIC TELEDENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-238-5161
Mailing Address - Street 1:2025 FAIRVIEW AVE E UNIT H
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-3575
Mailing Address - Country:US
Mailing Address - Phone:425-238-5161
Mailing Address - Fax:
Practice Address - Street 1:2025 FAIRVIEW AVE E UNIT H
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-3575
Practice Address - Country:US
Practice Address - Phone:425-238-5161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAWDLL7R80J93BOtherDRIVING LICENSE