Provider Demographics
NPI:1649475799
Name:MARTHA LAKE DENTAL CENTER
Entity type:Organization
Organization Name:MARTHA LAKE DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:T
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-787-2402
Mailing Address - Street 1:1233 164TH ST SW
Mailing Address - Street 2:STE #H
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98087
Mailing Address - Country:US
Mailing Address - Phone:425-787-2402
Mailing Address - Fax:425-787-5350
Practice Address - Street 1:1233 164TH ST SW
Practice Address - Street 2:STE #H
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98087
Practice Address - Country:US
Practice Address - Phone:425-787-2402
Practice Address - Fax:425-787-5350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE9941122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty