Provider Demographics
NPI:1629328638
Name:STEVEN P MARINKOVICH DDS
Entity Type:Organization
Organization Name:STEVEN P MARINKOVICH DDS
Other - Org Name:EVERGREEN DENTAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:MARINKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, ABDSM
Authorized Official - Phone:253-474-3223
Mailing Address - Street 1:5225 TACOMA MALL BLVD
Mailing Address - Street 2:SUITE E-104
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-7018
Mailing Address - Country:US
Mailing Address - Phone:253-474-3223
Mailing Address - Fax:253-473-6762
Practice Address - Street 1:5225 TACOMA MALL BLVD
Practice Address - Street 2:SUITE E-104
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-7018
Practice Address - Country:US
Practice Address - Phone:253-474-3223
Practice Address - Fax:253-473-6762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-17
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
WADE00004767332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty