MEDICARE: WASHINGTON DENTAL SERVICE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DE00005474	WA
2	1223G0001X	General Practice Dentistry	DE00005252	WA
3	1223G0001X	General Practice Dentistry	DE00006700	WA
4	1223G0001X	General Practice Dentistry	DE00005222	WA
5	1223P0221X	Pediatric Dentistry	DE00005772	WA
6	1223G0001X	General Practice Dentistry	DE00004485	WA

General Provider Information

NPI Number	:	1154631117
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WASHINGTON DENTAL SERVICE

Provider Business Mailing Address
First Line	:	9706 4TH AVE NE
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98115-2157
Country	:	US
Telephone Number	:	206-528-2337
Fax Number	:	206-985-4950

Provider Business Practice Location Address
First Line	:	9706 4TH AVE NE
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98115-2157
Country	:	US
Telephone Number	:	206-528-2337
Fax Number	:	206-985-4950

Authorized Official
Title or Position	:	CEO
Name	:	MS. LAURA SMITH
Credential	:	MPA
Telephone Number	:	206-528-2335

Provider Enumeration Date	:	10/08/2010
Last Update Date	:	10/08/2010

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Directions to “WASHINGTON DENTAL SERVICE ” Practice Location

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