Provider Demographics
NPI:1790018976
Name:SOUTH SEATTLE DENTAL
Entity Type:Organization
Organization Name:SOUTH SEATTLE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-772-6068
Mailing Address - Street 1:12616 RENTON AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98178-3711
Mailing Address - Country:US
Mailing Address - Phone:206-772-6068
Mailing Address - Fax:206-772-1231
Practice Address - Street 1:12616 RENTON AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98178-3711
Practice Address - Country:US
Practice Address - Phone:206-772-6068
Practice Address - Fax:206-772-1231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-06
Last Update Date:2009-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00010347261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5054291Medicaid