Provider Demographics
NPI:1760734842
Name:ADVANCED DENTAL & DENTURE PLLC
Entity Type:Organization
Organization Name:ADVANCED DENTAL & DENTURE PLLC
Other - Org Name:ADVANCED DENTAL & DENTURE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DENTURIES
Authorized Official - Prefix:
Authorized Official - First Name:QUOC
Authorized Official - Middle Name:WAN
Authorized Official - Last Name:NGO
Authorized Official - Suffix:
Authorized Official - Credentials:LD
Authorized Official - Phone:206-335-6468
Mailing Address - Street 1:17694 1ST AVE S
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98148-1729
Mailing Address - Country:US
Mailing Address - Phone:206-335-6468
Mailing Address - Fax:
Practice Address - Street 1:17694 1ST AVE S
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98148-1729
Practice Address - Country:US
Practice Address - Phone:206-335-6468
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000105121223G0001X
WADN00000449122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122400000XDental ProvidersDenturistGroup - Multi-Specialty