Provider Demographics
NPI:1578823852
Name:KEVIN XU D.D.S., M.S.,P.S., INC.
Entity Type:Organization
Organization Name:KEVIN XU D.D.S., M.S.,P.S., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:XU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-473-2166
Mailing Address - Street 1:5038 TACOMA MALL BLVD
Mailing Address - Street 2:STE. A
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-7103
Mailing Address - Country:US
Mailing Address - Phone:253-473-2166
Mailing Address - Fax:253-473-2167
Practice Address - Street 1:5038 TACOMA MALL BLVD
Practice Address - Street 2:STE. A
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-7103
Practice Address - Country:US
Practice Address - Phone:253-473-2166
Practice Address - Fax:253-473-2167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA69381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1821074527OtherINDIVIDUAL
WA1710957329OtherINDIVIDUAL