Provider Demographics
NPI:1467874917
Name:PT. DEFIANCE DENTAL CLINIC AND LAB
Entity Type:Organization
Organization Name:PT. DEFIANCE DENTAL CLINIC AND LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SOFYA
Authorized Official - Middle Name:V
Authorized Official - Last Name:KOCHUBEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-238-1783
Mailing Address - Street 1:5904 N 45TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-1902
Mailing Address - Country:US
Mailing Address - Phone:253-238-1783
Mailing Address - Fax:
Practice Address - Street 1:5904 N 45TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98407-1902
Practice Address - Country:US
Practice Address - Phone:253-238-1783
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA8905122300000X
WADN60141899122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty