Provider Demographics
NPI:1922359744
Name:LEGACY DENTAL GROUP PLLC
Entity Type:Organization
Organization Name:LEGACY DENTAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:V
Authorized Official - Last Name:KERR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:253-584-6200
Mailing Address - Street 1:9951 MICKELBERRY RD NW
Mailing Address - Street 2:SUITE #215
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8309
Mailing Address - Country:US
Mailing Address - Phone:360-692-9701
Mailing Address - Fax:
Practice Address - Street 1:9951 MICKELBERRY RD NW
Practice Address - Street 2:SUITE #215
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8309
Practice Address - Country:US
Practice Address - Phone:360-692-9701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty