Provider Demographics
NPI:1184135881
Name:REVIVE SMILES DENTISTRY, LLC
Entity type:Organization
Organization Name:REVIVE SMILES DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:S
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:206-829-8565
Mailing Address - Street 1:259 YALE AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109-5430
Mailing Address - Country:US
Mailing Address - Phone:206-829-8565
Mailing Address - Fax:206-739-5797
Practice Address - Street 1:259 YALE AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-5430
Practice Address - Country:US
Practice Address - Phone:206-829-8565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-20
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA9084261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental