Provider Demographics
NPI:1134847502
Name:PLATINUM DENTAL NORTHWEST LLC
Entity type:Organization
Organization Name:PLATINUM DENTAL NORTHWEST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BISHOP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-212-7646
Mailing Address - Street 1:120 AVENUE A STE A
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98290-2961
Mailing Address - Country:US
Mailing Address - Phone:425-212-7646
Mailing Address - Fax:360-282-0158
Practice Address - Street 1:6101 200TH ST SW STE 200
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-6077
Practice Address - Country:US
Practice Address - Phone:360-863-2517
Practice Address - Fax:360-282-0158
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PLATINUM DENTAL NORTHWEST LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty