Provider Demographics
NPI:1982092805
Name:RENTON SMILE DENTISTRY
Entity Type:Organization
Organization Name:RENTON SMILE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:NIKOLAEVA
Authorized Official - Last Name:MANCHESTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:206-802-8414
Mailing Address - Street 1:1107 SW GRADY WAY
Mailing Address - Street 2:SUITE 250
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-5217
Mailing Address - Country:US
Mailing Address - Phone:425-687-8860
Mailing Address - Fax:425-687-8863
Practice Address - Street 1:1107 SW GRADY WAY
Practice Address - Street 2:SUITE 250
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-5217
Practice Address - Country:US
Practice Address - Phone:425-687-8860
Practice Address - Fax:425-687-8863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-30
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60475234261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental