Provider Demographics
NPI:1720204266
Name:JED V. SANTIAGO, DDS, PLLC
Entity Type:Organization
Organization Name:JED V. SANTIAGO, DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JED
Authorized Official - Middle Name:VAL
Authorized Official - Last Name:SANTIAGO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-712-0800
Mailing Address - Street 1:18505 ALDERWOOD MALL PKWY
Mailing Address - Street 2:SUITE D
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98037-8012
Mailing Address - Country:US
Mailing Address - Phone:425-712-0800
Mailing Address - Fax:425-670-1125
Practice Address - Street 1:18505 ALDERWOOD MALL PKWY
Practice Address - Street 2:SUITE D
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98037-8012
Practice Address - Country:US
Practice Address - Phone:425-712-0800
Practice Address - Fax:425-670-1125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000093861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty