Provider Demographics
NPI:1942279997
Name:EDMONDS BAY DENTAL
Entity Type:Organization
Organization Name:EDMONDS BAY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:V
Authorized Official - Last Name:MISCHEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-775-5162
Mailing Address - Street 1:51 W DAYTON
Mailing Address - Street 2:SUITE 301
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020
Mailing Address - Country:US
Mailing Address - Phone:425-775-5162
Mailing Address - Fax:425-491-8100
Practice Address - Street 1:51 W DAYTON
Practice Address - Street 2:SUITE 301
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020
Practice Address - Country:US
Practice Address - Phone:425-775-5162
Practice Address - Fax:425-491-8100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00005091122300000X
WADE0010360122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5049457Medicaid