Provider Demographics
NPI:1659480622
Name:LOURDES M ACUESTA DDS PS
Entity Type:Organization
Organization Name:LOURDES M ACUESTA DDS PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOURDES
Authorized Official - Middle Name:MANCOL
Authorized Official - Last Name:ACUESTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:206-322-7706
Mailing Address - Street 1:1500 FAIRVIEW AVE E
Mailing Address - Street 2:SUITE 302
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-3727
Mailing Address - Country:US
Mailing Address - Phone:206-322-7706
Mailing Address - Fax:206-329-5214
Practice Address - Street 1:1500 FAIRVIEW AVE E
Practice Address - Street 2:SUITE 302
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-3727
Practice Address - Country:US
Practice Address - Phone:206-322-7706
Practice Address - Fax:206-329-5214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000057771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5000393Medicaid