Provider Demographics
NPI:1548779515
Name:NORTHWEST CENTER FOR PROSTHODONTICS
Entity Type:Organization
Organization Name:NORTHWEST CENTER FOR PROSTHODONTICS
Other - Org Name:OLYMPIA SMILE DESIGN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MANCHESTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:406-599-4642
Mailing Address - Street 1:3425 ENSIGN RD NE STE 210
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5063
Mailing Address - Country:US
Mailing Address - Phone:406-599-4642
Mailing Address - Fax:
Practice Address - Street 1:3425 ENSIGN RD NE STE 210
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5063
Practice Address - Country:US
Practice Address - Phone:406-599-4642
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE605796091223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty