1487845327 NPI number — PROVAIL DENTAL CLINIC

Table of content: (NPI 1487845327)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487845327 NPI number — PROVAIL DENTAL CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVAIL DENTAL CLINIC
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:
1487845327
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3670 STONE WAY N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98103-8004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-363-7303
Provider Business Mailing Address Fax Number:
206-826-0181

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10215 LAKE CITY WAY NE STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98125-7758
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-632-2612
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HATZENBELER
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
206-826-1044

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , 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: 5716808 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com