Provider Demographics
NPI:1841444981
Name:TACOMA DENTURE CLINIC
Entity type:Organization
Organization Name:TACOMA DENTURE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-475-8570
Mailing Address - Street 1:3712 S CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-5715
Mailing Address - Country:US
Mailing Address - Phone:253-475-8570
Mailing Address - Fax:253-475-8577
Practice Address - Street 1:3712 S CEDAR ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-5715
Practice Address - Country:US
Practice Address - Phone:253-475-8570
Practice Address - Fax:253-475-8577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA53971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5781604Medicaid
WA5012976Medicaid
WA5042791Medicaid
WA5042791Medicaid