Healthcare Provider Details

I. General information

NPI: 1982900130
Provider Name (Legal Business Name): EVERETT EMERGENCY DENTAL CARE, USA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2011
Last Update Date: 02/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1338 N 143RD AVENUE CIR
OMAHA NE
68154-5108
US

IV. Provider business mailing address

10305 19TH AVE SE SUITE B
EVERETT WA
98208-4218
US

V. Phone/Fax

Practice location:
  • Phone: 402-597-1186
  • Fax: 402-393-2886
Mailing address:
  • Phone: 425-357-0911
  • Fax: 425-357-0330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60065986
License Number StateWA

VIII. Authorized Official

Name: MR. MICHAEL OBENG
Title or Position: OWNER/PRESIDENT
Credential: DDS
Phone: 402-597-1186