Provider Demographics
NPI:1245650365
Name:FIRCREST CHILDREN'S DENTISTRY
Entity type:Organization
Organization Name:FIRCREST CHILDREN'S DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BECK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:253-564-2222
Mailing Address - Street 1:1501 REGENTS BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:FIRCREST
Mailing Address - State:WA
Mailing Address - Zip Code:98466-6098
Mailing Address - Country:US
Mailing Address - Phone:253-564-2222
Mailing Address - Fax:
Practice Address - Street 1:1501 REGENTS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:FIRCREST
Practice Address - State:WA
Practice Address - Zip Code:98466-6098
Practice Address - Country:US
Practice Address - Phone:253-564-2222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-16
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60140820261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA12-23-P0221OtherTAXONOMY, PEDIATRIC DENTISTRY
WA1033368006Medicaid