Provider Demographics
NPI:1659597474
Name:AESTHETIC DENTAL CENTER
Entity Type:Organization
Organization Name:AESTHETIC DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RENE
Authorized Official - Middle Name:
Authorized Official - Last Name:YOSHIZAWA
Authorized Official - Suffix:
Authorized Official - Credentials:MHSA
Authorized Official - Phone:425-825-0626
Mailing Address - Street 1:9800 NE 120TH PL STE D
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-4220
Mailing Address - Country:US
Mailing Address - Phone:425-825-0626
Mailing Address - Fax:425-823-9654
Practice Address - Street 1:9800 NE 120TH PL STE D
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-4220
Practice Address - Country:US
Practice Address - Phone:425-825-0626
Practice Address - Fax:425-823-9654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE87291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5047725Medicaid