Provider Demographics
NPI:1760936637
Name:FEDERAL WAY DENTAL CLINIC
Entity Type:Organization
Organization Name:FEDERAL WAY DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:YONG
Authorized Official - Middle Name:K
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-839-8106
Mailing Address - Street 1:2016 S 320TH ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-5453
Mailing Address - Country:US
Mailing Address - Phone:253-839-8106
Mailing Address - Fax:253-941-7989
Practice Address - Street 1:2016 S 320TH ST
Practice Address - Street 2:SUITE F
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5453
Practice Address - Country:US
Practice Address - Phone:253-839-8106
Practice Address - Fax:253-941-7989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00009186305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization