Provider Demographics
NPI:1831534155
Name:CLOVERDALE FAMILY DENTISTRY
Entity type:Organization
Organization Name:CLOVERDALE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:FUJII
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:206-762-2337
Mailing Address - Street 1:1415 S CLOVERDALE ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98108-4826
Mailing Address - Country:US
Mailing Address - Phone:206-762-2337
Mailing Address - Fax:206-762-0344
Practice Address - Street 1:1415 S CLOVERDALE ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98108-4826
Practice Address - Country:US
Practice Address - Phone:206-762-2337
Practice Address - Fax:206-762-0344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-30
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000085201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty