Provider Demographics
NPI:1619308137
Name:FEDERAL WAY DENTAL LLC
Entity Type:Organization
Organization Name:FEDERAL WAY DENTAL LLC
Other - Org Name:COMFORT DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:NANDITA
Authorized Official - Middle Name:
Authorized Official - Last Name:LILLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-839-1007
Mailing Address - Street 1:31401 PACIFIC HWY S
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-5403
Mailing Address - Country:US
Mailing Address - Phone:253-839-1007
Mailing Address - Fax:253-839-4035
Practice Address - Street 1:31401 PACIFIC HWY S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5403
Practice Address - Country:US
Practice Address - Phone:253-839-1007
Practice Address - Fax:253-839-4035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60398437122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty