Provider Demographics
NPI:1780733204
Name:OLYMPIC DENTAL CENTER, LLC
Entity type:Organization
Organization Name:OLYMPIC DENTAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTURIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPD
Authorized Official - Phone:360-438-8299
Mailing Address - Street 1:4408 PACIFIC AVE SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-1119
Mailing Address - Country:US
Mailing Address - Phone:360-438-8299
Mailing Address - Fax:360-438-1399
Practice Address - Street 1:4408 PACIFIC AVE SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1119
Practice Address - Country:US
Practice Address - Phone:360-438-8299
Practice Address - Fax:360-438-1399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5040258Medicaid
WA1412978OtherUNITED CONCORDIA