Provider Demographics
NPI:1831415199
Name:HSU DENTAL CLINIC PLLC
Entity type:Organization
Organization Name:HSU DENTAL CLINIC PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:C
Authorized Official - Last Name:HSU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:206-362-2456
Mailing Address - Street 1:11545 15TH AVE NE STE 201
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-6358
Mailing Address - Country:US
Mailing Address - Phone:206-362-2456
Mailing Address - Fax:206-362-3675
Practice Address - Street 1:11545 15TH AVE NE STE 201
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98125-6358
Practice Address - Country:US
Practice Address - Phone:206-362-2456
Practice Address - Fax:206-362-3675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-12
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000101471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5049838Medicaid