Provider Demographics
NPI:1578740759
Name:PUGET SOUND DENTUES
Entity Type:Organization
Organization Name:PUGET SOUND DENTUES
Other - Org Name:PARKLAND DENTURE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOEY
Authorized Official - Middle Name:E
Authorized Official - Last Name:BERLANGA
Authorized Official - Suffix:JR
Authorized Official - Credentials:LD
Authorized Official - Phone:253-752-8068
Mailing Address - Street 1:601 N PUGET SOUND AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98406-5425
Mailing Address - Country:US
Mailing Address - Phone:253-752-8068
Mailing Address - Fax:253-756-3219
Practice Address - Street 1:601 N PUGET SOUND AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-5425
Practice Address - Country:US
Practice Address - Phone:253-752-8068
Practice Address - Fax:253-756-3219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000135122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5022694Medicaid
WA5022694Medicaid
WA=========OtherWDS
WA=========OtherCIGNA
WA=========OtherSTANDARD INS