Provider Demographics
NPI:1730282054
Name:GORDON B ROSENGREN, DDS, INC, PS
Entity Type:Organization
Organization Name:GORDON B ROSENGREN, DDS, INC, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:B
Authorized Official - Last Name:ROSENGREN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-859-0123
Mailing Address - Street 1:24722 104TH AVE SE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-5322
Mailing Address - Country:US
Mailing Address - Phone:253-859-0123
Mailing Address - Fax:253-859-5864
Practice Address - Street 1:24722 104TH AVE SE
Practice Address - Street 2:SUITE 201
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-5322
Practice Address - Country:US
Practice Address - Phone:253-859-0123
Practice Address - Fax:253-859-5864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00004446261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental