1194898379 NPI number — NORTHWEST INSTITUTE OF COSMETIC DENTISTRY

Table of content: (NPI 1194898379)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194898379 NPI number — NORTHWEST INSTITUTE OF COSMETIC DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST INSTITUTE OF COSMETIC 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:
6
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:
1194898379
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15710 NE 24TH STREET
Provider Second Line Business Mailing Address:
#B
Provider Business Mailing Address City Name:
BELLEVUE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-643-7100
Provider Business Mailing Address Fax Number:
425-644-1426

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15710 NE 24TH STREET
Provider Second Line Business Practice Location Address:
#B
Provider Business Practice Location Address City Name:
BELLEVUE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-643-7100
Provider Business Practice Location Address Fax Number:
425-644-1426
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DER OVANESSIAN
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
425-643-7100

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  39144 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: 7600 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5034913 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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