Provider Demographics
NPI:1487845327
Name:PROVAIL DENTAL CLINIC
Entity Type:Organization
Organization Name:PROVAIL DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HATZENBELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-826-1044
Mailing Address - Street 1:3670 STONE WAY N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-8004
Mailing Address - Country:US
Mailing Address - Phone:206-363-7303
Mailing Address - Fax:206-826-0181
Practice Address - Street 1:10215 LAKE CITY WAY NE STE E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98125-7758
Practice Address - Country:US
Practice Address - Phone:206-632-2612
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5716808Medicaid