Provider Demographics
NPI:1336441617
Name:MYDENTIST DENTAL CENTER
Entity Type:Organization
Organization Name:MYDENTIST DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ANTONELA
Authorized Official - Middle Name:
Authorized Official - Last Name:POLOTANU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-277-7592
Mailing Address - Street 1:333 RAINIER AVE N
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-5358
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 RAINIER AVE N
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-5358
Practice Address - Country:US
Practice Address - Phone:425-277-7592
Practice Address - Fax:425-277-7590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-19
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 00010919261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental