Provider Demographics
NPI:1437690955
Name:SOUTH BEACH DENTAL CLINIC
Entity Type:Organization
Organization Name:SOUTH BEACH DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:W
Authorized Official - Last Name:PEGG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:360-268-6225
Mailing Address - Street 1:PO BOX 2049
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:WA
Mailing Address - Zip Code:98595-2049
Mailing Address - Country:US
Mailing Address - Phone:360-268-6225
Mailing Address - Fax:360-268-6095
Practice Address - Street 1:509 S MONTESANO ST
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:WA
Practice Address - Zip Code:98595
Practice Address - Country:US
Practice Address - Phone:360-268-6225
Practice Address - Fax:360-268-6095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-16
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE0083501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty