Provider Demographics
NPI:1649554189
Name:ALLIED FAMILY DENTAL
Entity type:Organization
Organization Name:ALLIED FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIMITRI
Authorized Official - Middle Name:
Authorized Official - Last Name:RABINOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-434-7117
Mailing Address - Street 1:14212 AMBAUM BLVD SW
Mailing Address - Street 2:SUITE 302
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-1449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14212 AMBAUM BLVD SW
Practice Address - Street 2:SUITE 302
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-1449
Practice Address - Country:US
Practice Address - Phone:206-244-7992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR. NHI PHAM DDS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5032388Medicaid