Provider Demographics
NPI:1891158317
Name:KORSMO & HENRY DDD PS
Entity Type:Organization
Organization Name:KORSMO & HENRY DDD PS
Other - Org Name:PUYALLUP FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSARIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-770-0529
Mailing Address - Street 1:5620 112TH ST E
Mailing Address - Street 2:SUITE 250
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-3206
Mailing Address - Country:US
Mailing Address - Phone:253-770-0529
Mailing Address - Fax:253-770-9638
Practice Address - Street 1:5620 112TH ST E
Practice Address - Street 2:SUITE 250
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3206
Practice Address - Country:US
Practice Address - Phone:253-770-0529
Practice Address - Fax:253-770-9638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA52541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty