Provider Demographics
NPI:1841318912
Name:OLYMPIC DENTAL CENTER LLC
Entity type:Organization
Organization Name:OLYMPIC DENTAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LD
Authorized Official - Phone:360-736-0795
Mailing Address - Street 1:716 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-2847
Mailing Address - Country:US
Mailing Address - Phone:360-736-0795
Mailing Address - Fax:360-330-1637
Practice Address - Street 1:716 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-2847
Practice Address - Country:US
Practice Address - Phone:360-736-0795
Practice Address - Fax:360-330-1637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
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
WA5038377Medicaid
WA1412978OtherUNITED CONCORDIA PROVIDER