Provider Demographics
NPI:1639381874
Name:IVY DENTAL FOR KIDS
Entity Type:Organization
Organization Name:IVY DENTAL FOR KIDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:YOON
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-275-9977
Mailing Address - Street 1:18623 HWY 99
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98037-4552
Mailing Address - Country:US
Mailing Address - Phone:425-275-9977
Mailing Address - Fax:425-275-9979
Practice Address - Street 1:18623 HWY 99
Practice Address - Street 2:SUITE 210
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98037-4552
Practice Address - Country:US
Practice Address - Phone:425-275-9977
Practice Address - Fax:425-275-9979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA94911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5041611Medicaid