Provider Demographics
NPI:1649582529
Name:IMAGE FAMILY DENTAL, LLC
Entity Type:Organization
Organization Name:IMAGE FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OFFICE MANANGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:TUAN
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-656-2919
Mailing Address - Street 1:18123 E VALLEY HWY
Mailing Address - Street 2:SUITE B-104
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-1007
Mailing Address - Country:US
Mailing Address - Phone:425-656-2919
Mailing Address - Fax:425-656-7878
Practice Address - Street 1:18123 E VALLEY HWY
Practice Address - Street 2:SUITE B-104
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-1007
Practice Address - Country:US
Practice Address - Phone:425-656-2919
Practice Address - Fax:425-656-7878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-08
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5050893Medicaid