Provider Demographics
NPI:1649460288
Name:CHC OF SNOHOMISH COUNTY 112TH DENTAL
Entity type:Organization
Organization Name:CHC OF SNOHOMISH COUNTY 112TH DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-789-3700
Mailing Address - Street 1:PO BOX 13060
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-3060
Mailing Address - Country:US
Mailing Address - Phone:425-789-3700
Mailing Address - Fax:425-789-3754
Practice Address - Street 1:1019 112TH ST SW
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204
Practice Address - Country:US
Practice Address - Phone:425-551-6001
Practice Address - Fax:425-551-6008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA5010921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5010921Medicaid