Provider Demographics
NPI:1932957909
Name:COTTAGE LAKE FAMILY DENTISTRY, PLLC
Entity Type:Organization
Organization Name:COTTAGE LAKE FAMILY DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICK
Authorized Official - Middle Name:
Authorized Official - Last Name:SUNDIAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-300-5933
Mailing Address - Street 1:19150 NE WOODINVILLE DUVALL RD
Mailing Address - Street 2:
Mailing Address - City:WOODINVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98077-9477
Mailing Address - Country:US
Mailing Address - Phone:425-788-8900
Mailing Address - Fax:425-788-3936
Practice Address - Street 1:19150 NE WOODINVILLE DUVALL RD
Practice Address - Street 2:
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98077-9477
Practice Address - Country:US
Practice Address - Phone:425-788-8900
Practice Address - Fax:425-788-3936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-07
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty