Provider Demographics
NPI:1891158861
Name:KIDS CHOICE DENTAL PUYALLUP, LLC
Entity Type:Organization
Organization Name:KIDS CHOICE DENTAL PUYALLUP, LLC
Other - Org Name:KIDS CHOICE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHADEED
Authorized Official - Middle Name:S
Authorized Official - Last Name:VIRK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:253-848-7000
Mailing Address - Street 1:9317 113TH ST E
Mailing Address - Street 2:SUITE A
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-3876
Mailing Address - Country:US
Mailing Address - Phone:253-848-7000
Mailing Address - Fax:253-604-0598
Practice Address - Street 1:9317 113TH ST E
Practice Address - Street 2:SUITE A
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3876
Practice Address - Country:US
Practice Address - Phone:253-848-7000
Practice Address - Fax:253-604-0598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-29
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6035913861223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2010685Medicaid