Provider Demographics
NPI:1639536097
Name:HARBOR KIDS DENTAL & ORTHODONTICS OF TACOMA PC
Entity Type:Organization
Organization Name:HARBOR KIDS DENTAL & ORTHODONTICS OF TACOMA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:VANBIBBER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:253-537-5437
Mailing Address - Street 1:4002 S M ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98418-3800
Mailing Address - Country:US
Mailing Address - Phone:253-474-0606
Mailing Address - Fax:253-537-5438
Practice Address - Street 1:4002 S M ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418-3800
Practice Address - Country:US
Practice Address - Phone:253-474-0606
Practice Address - Fax:253-537-5438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE602827271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADE60282727OtherDENTAL LICENSE