1639736119 NPI number — SOUTHCENTER CHILDREN'S DENTISTRY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639736119 NPI number — SOUTHCENTER CHILDREN'S DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHCENTER CHILDREN'S DENTISTRY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639736119
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2141 WASHINGTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FERNDALE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98248-9183
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-676-9222
Provider Business Mailing Address Fax Number:
360-676-9223

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
411 STRANDER BLVD STE 303
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUKWILA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98188-2924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-575-1130
Provider Business Practice Location Address Fax Number:
206-575-1133
Provider Enumeration Date:
05/21/2019

Additional Information

Authorized Official

Authorized Official Last Name:
YEH
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
206-575-1130

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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