Provider Demographics
NPI:1609094705
Name:KEIKO J WADA DMD
Entity Type:Organization
Organization Name:KEIKO J WADA DMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEIKO
Authorized Official - Middle Name:
Authorized Official - Last Name:WADA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:253-858-8158
Mailing Address - Street 1:7108 PIONEER WAY STE E
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-1178
Mailing Address - Country:US
Mailing Address - Phone:253-858-8158
Mailing Address - Fax:253-858-5029
Practice Address - Street 1:7108 PIONEER WAY STE E
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1178
Practice Address - Country:US
Practice Address - Phone:253-858-8158
Practice Address - Fax:253-858-5029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00006685122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5514609Medicaid