Provider Demographics
NPI:1689188336
Name:MEADOWDALE DENTAL CENTER
Entity Type:Organization
Organization Name:MEADOWDALE DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:M
Authorized Official - Last Name:DIVANO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-692-4705
Mailing Address - Street 1:7500 OLD MILITARY RD NE STE 201
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98311-3242
Mailing Address - Country:US
Mailing Address - Phone:360-692-4705
Mailing Address - Fax:360-692-4846
Practice Address - Street 1:7500 OLD MILITARY RD NE STE 201
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98311-3242
Practice Address - Country:US
Practice Address - Phone:360-692-4705
Practice Address - Fax:360-692-4846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-16
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADR00010155122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADE00010155OtherSTATE LIC