Provider Demographics
NPI:1770826927
Name:HOUSE, LEE, MAST, MCDONALD AND NELSON, PC
Entity Type:Organization
Organization Name:HOUSE, LEE, MAST, MCDONALD AND NELSON, PC
Other - Org Name:A KIDS PLACE DENTISTRY FOR CHILDREN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LANETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCINTOSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-396-1011
Mailing Address - Street 1:451 DUVALL AVE NE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98059-4675
Mailing Address - Country:US
Mailing Address - Phone:425-228-5437
Mailing Address - Fax:425-663-7990
Practice Address - Street 1:451 DUVALL AVE NE
Practice Address - Street 2:SUITE 140
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98059-4675
Practice Address - Country:US
Practice Address - Phone:425-228-5437
Practice Address - Fax:425-663-7990
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOUSE, LEE, MAST, MCDONALD AND NELSON, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-05
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5048921Medicaid