Provider Demographics
NPI:1942663927
Name:NORTH TACOMA PEDIATRIC DENTISTRY AND ORTHODONTICS LLC
Entity Type:Organization
Organization Name:NORTH TACOMA PEDIATRIC DENTISTRY AND ORTHODONTICS LLC
Other - Org Name:NORTH TACOMA PEDIATRIC DENTISTRY AND ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHADEEP
Authorized Official - Middle Name:S
Authorized Official - Last Name:VIRK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:253-627-5027
Mailing Address - Street 1:3402 S 18TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1903
Mailing Address - Country:US
Mailing Address - Phone:253-627-5027
Mailing Address - Fax:
Practice Address - Street 1:3402 S 18TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1903
Practice Address - Country:US
Practice Address - Phone:253-627-5027
Practice Address - Fax:253-383-7747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6035913841223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2010685Medicaid