Provider Demographics
NPI:1811026628
Name:MOBILE DENT INC PS
Entity Type:Organization
Organization Name:MOBILE DENT INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:E
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-747-5424
Mailing Address - Street 1:13300 SE 30TH ST SUITE 101
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005
Mailing Address - Country:US
Mailing Address - Phone:425-747-5424
Mailing Address - Fax:425-746-6332
Practice Address - Street 1:13300 SE 30TH ST SUITE 101
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005
Practice Address - Country:US
Practice Address - Phone:425-747-5424
Practice Address - Fax:425-746-6332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA5092122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5531108Medicaid