Healthcare Provider Details

I. General information

NPI: 1548454655
Provider Name (Legal Business Name): WASHINGTON STATE SMILE PARTNERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2007
Last Update Date: 08/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 WINSLOW WAY W 302
BAINBRIDGE ISLAND WA
98110-4915
US

IV. Provider business mailing address

221 WINSLOW WAY W 302
BAINBRIDGE ISLAND WA
98110-4915
US

V. Phone/Fax

Practice location:
  • Phone: 206-909-1365
  • Fax:
Mailing address:
  • Phone: 206-909-1365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN ANN MILLS
Title or Position: PROGRAM DIRECTOR
Credential: RDH
Phone: 206-909-1365