Provider Demographics
NPI:1568615052
Name:LAWRENCE E. MAST DDS
Entity Type:Organization
Organization Name:LAWRENCE E. MAST DDS
Other - Org Name:SNOQUALMIE VALLEY KIDS DENTIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LANETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCINTOSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-455-0784
Mailing Address - Street 1:34929 SE RIDGE ST STE 220
Mailing Address - Street 2:
Mailing Address - City:SNOQUALMIE
Mailing Address - State:WA
Mailing Address - Zip Code:98065-6306
Mailing Address - Country:US
Mailing Address - Phone:425-396-1011
Mailing Address - Fax:425-396-1258
Practice Address - Street 1:34929 SE RIDGE ST STE 220
Practice Address - Street 2:
Practice Address - City:SNOQUALMIE
Practice Address - State:WA
Practice Address - Zip Code:98065-6306
Practice Address - Country:US
Practice Address - Phone:425-396-1011
Practice Address - Fax:425-396-1258
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAWRENCE E. MAST DDS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-28
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA42331223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5018171Medicaid
WA5052956Medicaid