Provider Demographics
NPI:1558803171
Name:J.A. DENTURE CLINIC LLC
Entity Type:Organization
Organization Name:J.A. DENTURE CLINIC LLC
Other - Org Name:J.A. DENTAL LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATALIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUKASHOVA
Authorized Official - Suffix:
Authorized Official - Credentials:DPD
Authorized Official - Phone:206-566-8900
Mailing Address - Street 1:3226 208TH PL SW
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-7884
Mailing Address - Country:US
Mailing Address - Phone:206-566-8900
Mailing Address - Fax:
Practice Address - Street 1:3226 208TH PL SW
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-7884
Practice Address - Country:US
Practice Address - Phone:206-566-8900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-14
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN60457526122400000X
WA603550350292200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Multi-Specialty
No292200000XLaboratoriesDental LaboratoryGroup - Multi-Specialty