Provider Demographics
NPI:1376010652
Name:FIRCREST FAMILY DENTAL
Entity type:Organization
Organization Name:FIRCREST FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NARI
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-292-0596
Mailing Address - Street 1:3670 BRIDGEPORT WAY W UNIT B
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4413
Mailing Address - Country:US
Mailing Address - Phone:253-212-3430
Mailing Address - Fax:
Practice Address - Street 1:4040 ORCHARD ST W STE 200
Practice Address - Street 2:
Practice Address - City:FIRCREST
Practice Address - State:WA
Practice Address - Zip Code:98466-6615
Practice Address - Country:US
Practice Address - Phone:253-292-0596
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1023163425Medicaid