Provider Demographics
NPI:1639393309
Name:ABC DENTISTRY
Entity Type:Organization
Organization Name:ABC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LUC
Authorized Official - Middle Name:
Authorized Official - Last Name:HOANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-878-5665
Mailing Address - Street 1:22625 PACIFIC HWY S
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-5110
Mailing Address - Country:US
Mailing Address - Phone:206-878-5665
Mailing Address - Fax:206-870-1504
Practice Address - Street 1:22625 PACIFIC HWY S
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-5110
Practice Address - Country:US
Practice Address - Phone:206-878-5665
Practice Address - Fax:206-870-1504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2855305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5040043Medicaid