Provider Demographics
NPI:1831624402
Name:MINH DAU, DDS AND RAYMOND PARK, DDS PLLC
Entity type:Organization
Organization Name:MINH DAU, DDS AND RAYMOND PARK, DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GOVERNOR
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-284-9886
Mailing Address - Street 1:3105 ALDERWOOD MALL BLVD
Mailing Address - Street 2:SUITE 117
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4703
Mailing Address - Country:US
Mailing Address - Phone:425-284-9886
Mailing Address - Fax:
Practice Address - Street 1:3105 ALDERWOOD MALL BLVD
Practice Address - Street 2:SUITE 117
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-4703
Practice Address - Country:US
Practice Address - Phone:425-284-9886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE604671951223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1861743205Medicaid
WA1548521248Medicaid