1790817005 NPI number — PAPER STREET PERIODONTICS & IMPLANT DENTRISTRY

Table of content: (NPI 1790817005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790817005 NPI number — PAPER STREET PERIODONTICS & IMPLANT DENTRISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAPER STREET PERIODONTICS & IMPLANT DENTRISTRY
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:
1790817005
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2505 S 320TH ST
Provider Second Line Business Mailing Address:
SUITE 330
Provider Business Mailing Address City Name:
FEDERAL WAY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98003-5400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-400-0800
Provider Business Mailing Address Fax Number:
253-874-9068

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2505 S 320TH ST
Provider Second Line Business Practice Location Address:
SUITE 330
Provider Business Practice Location Address City Name:
FEDERAL WAY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98003-5400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-400-0800
Provider Business Practice Location Address Fax Number:
253-874-9068
Provider Enumeration Date:
03/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KANG
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
PERIODONTIST
Authorized Official Telephone Number:
206-400-0800

Provider Taxonomy Codes

  • Taxonomy code: 1223P0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DE00010542 . This is a "STATE LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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