Provider Demographics
NPI:1588805626
Name:WESTSIDE SMILE DENTAL LLC
Entity Type:Organization
Organization Name:WESTSIDE SMILE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTURIST
Authorized Official - Prefix:
Authorized Official - First Name:PHONG
Authorized Official - Middle Name:ANH
Authorized Official - Last Name:VONG
Authorized Official - Suffix:
Authorized Official - Credentials:LD
Authorized Official - Phone:206-762-7222
Mailing Address - Street 1:9670 14TH AVE SW UNIT AB
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98106-2876
Mailing Address - Country:US
Mailing Address - Phone:206-762-7222
Mailing Address - Fax:206-762-7783
Practice Address - Street 1:9670 14TH AVE SW UNIT AB
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98106-2876
Practice Address - Country:US
Practice Address - Phone:206-762-7222
Practice Address - Fax:206-762-7783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-19
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN327122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty