Provider Demographics
NPI:1013311729
Name:SERENITY DENTAL
Entity Type:Organization
Organization Name:SERENITY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUPRIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOVERDHANAM
Authorized Official - Suffix:
Authorized Official - Credentials:BDS,MS
Authorized Official - Phone:360-696-0471
Mailing Address - Street 1:6614 E MILL PLAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-7458
Mailing Address - Country:US
Mailing Address - Phone:360-696-0471
Mailing Address - Fax:360-993-8881
Practice Address - Street 1:6614 E MILL PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-7458
Practice Address - Country:US
Practice Address - Phone:360-696-0471
Practice Address - Fax:360-993-8881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty