Provider Demographics
NPI:1760695282
Name:NORTHSHORE DENTAL CENTER LLC
Entity Type:Organization
Organization Name:NORTHSHORE DENTAL CENTER LLC
Other - Org Name:NORTHSHORE DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:VO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-785-8305
Mailing Address - Street 1:18404 104TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-3414
Mailing Address - Country:US
Mailing Address - Phone:425-241-2960
Mailing Address - Fax:425-486-2712
Practice Address - Street 1:18404 104TH AVE NE
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3414
Practice Address - Country:US
Practice Address - Phone:425-486-2422
Practice Address - Fax:425-486-2712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00007951122300000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty