Provider Demographics
NPI:1023338522
Name:MAPLE VALLEY DENTISTRY PROFESSIONALS
Entity type:Organization
Organization Name:MAPLE VALLEY DENTISTRY PROFESSIONALS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNARDO
Authorized Official - Middle Name:EZEQUIEL
Authorized Official - Last Name:TAINA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-433-0600
Mailing Address - Street 1:24015 SE KENT KANGLEY RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-6802
Mailing Address - Country:US
Mailing Address - Phone:425-433-0600
Mailing Address - Fax:425-433-0877
Practice Address - Street 1:24015 SE KENT KANGLEY RD
Practice Address - Street 2:SUITE C
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-6802
Practice Address - Country:US
Practice Address - Phone:425-433-0600
Practice Address - Fax:425-433-0877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-07
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000093061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty