Provider Demographics
NPI:1619350857
Name:DA VINCI DENTAL LLC
Entity Type:Organization
Organization Name:DA VINCI DENTAL LLC
Other - Org Name:KALM DENTAL SPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BEAU
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-760-2704
Mailing Address - Street 1:909 112TH AVE NE
Mailing Address - Street 2:SUITE P-104
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-8580
Mailing Address - Country:US
Mailing Address - Phone:425-409-9999
Mailing Address - Fax:888-507-5181
Practice Address - Street 1:909 112TH AVE NE
Practice Address - Street 2:SUITE P-104
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-8580
Practice Address - Country:US
Practice Address - Phone:425-409-9999
Practice Address - Fax:888-507-5181
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DA VINCI DENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009161122300000X
WADE00011082122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty