Provider Demographics
NPI:1568841799
Name:DAVID CARL OBENCHAIN DDS, PLLC
Entity Type:Organization
Organization Name:DAVID CARL OBENCHAIN DDS, PLLC
Other - Org Name:WISDOM TEETH & ORAL SURGERY CENTER OF SEATTLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ORAL & MAXILLOFACIAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:OBENCHAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-740-4961
Mailing Address - Street 1:PO BOX 16068
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-1055
Mailing Address - Country:US
Mailing Address - Phone:402-740-4961
Mailing Address - Fax:206-990-0800
Practice Address - Street 1:3295 SW AVALON WAY
Practice Address - Street 2:DENTAL SUITE
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98126-1055
Practice Address - Country:US
Practice Address - Phone:206-561-2345
Practice Address - Fax:206-990-0800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-20
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE601023381223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2067882Medicaid