Provider Demographics
NPI:1417506486
Name:WASHINGTON DENTAL FEDERAL WAY, LLC
Entity Type:Organization
Organization Name:WASHINGTON DENTAL FEDERAL WAY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:YONG
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-592-2442
Mailing Address - Street 1:4040 ORCHARD ST W STE 200
Mailing Address - Street 2:
Mailing Address - City:FIRCREST
Mailing Address - State:WA
Mailing Address - Zip Code:98466-6615
Mailing Address - Country:US
Mailing Address - Phone:253-393-2700
Mailing Address - Fax:
Practice Address - Street 1:31515 PETE VON REICHBAUER WAY S UNIT 108
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5599
Practice Address - Country:US
Practice Address - Phone:206-592-2442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty