Provider Demographics
NPI:1851775514
Name:HARBOR KIDS DENTAL PLLC
Entity Type:Organization
Organization Name:HARBOR KIDS DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:VANBIBBER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-231-6682
Mailing Address - Street 1:1148 72ND ST E
Mailing Address - Street 2:SUITE B
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98404-1705
Mailing Address - Country:US
Mailing Address - Phone:253-537-5437
Mailing Address - Fax:253-537-5438
Practice Address - Street 1:216 W HERON ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-6225
Practice Address - Country:US
Practice Address - Phone:360-532-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE602827271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty