Provider Demographics
NPI:1477798544
Name:RUSSELL S VALENTINE DDS PS INC
Entity Type:Organization
Organization Name:RUSSELL S VALENTINE DDS PS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:S
Authorized Official - Last Name:VALENTINE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-475-4631
Mailing Address - Street 1:220 S 38TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98418-7807
Mailing Address - Country:US
Mailing Address - Phone:253-475-4631
Mailing Address - Fax:
Practice Address - Street 1:220 S 38TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418-7807
Practice Address - Country:US
Practice Address - Phone:253-475-4631
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA7290261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA846654OtherUNITED CONCORDIA