Provider Demographics
NPI:1801373683
Name:SOUTH SOUND FAMILY DENTISTRY
Entity Type:Organization
Organization Name:SOUTH SOUND FAMILY DENTISTRY
Other - Org Name:SOUTH SOUND FAMILY DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:A
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PS INC
Authorized Official - Phone:253-582-2408
Mailing Address - Street 1:3702 BRIDGEPORT WAY W STE A
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4438
Mailing Address - Country:US
Mailing Address - Phone:253-582-2408
Mailing Address - Fax:253-584-7024
Practice Address - Street 1:703 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5191
Practice Address - Country:US
Practice Address - Phone:360-459-3400
Practice Address - Fax:360-459-9700
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROL A. O'BRIEN, DDS, PS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000087989261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental