Provider Demographics
NPI: | 1851459069 |
---|---|
Name: | LILLY DENTURE CENTER, INC |
Entity Type: | Organization |
Organization Name: | LILLY DENTURE CENTER, INC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | DENTURIST |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | PATRICK |
Authorized Official - Middle Name: | M |
Authorized Official - Last Name: | CARBONE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DPD |
Authorized Official - Phone: | 360-412-0812 |
Mailing Address - Street 1: | 200 LILLY RD NE STE A |
Mailing Address - Street 2: | |
Mailing Address - City: | OLYMPIA |
Mailing Address - State: | WA |
Mailing Address - Zip Code: | 98506-5080 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 360-412-0812 |
Mailing Address - Fax: | 360-412-0814 |
Practice Address - Street 1: | 200 LILLY RD NE STE A |
Practice Address - Street 2: | |
Practice Address - City: | OLYMPIA |
Practice Address - State: | WA |
Practice Address - Zip Code: | 98506-5080 |
Practice Address - Country: | US |
Practice Address - Phone: | 360-412-0812 |
Practice Address - Fax: | 360-412-0814 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-12-04 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WA | DN00000194 | 122400000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 122400000X | Dental Providers | Denturist | Group - Single Specialty |