Healthcare Provider Details

I. General information

NPI: 1679104079
Provider Name (Legal Business Name): IDEAL SMILES DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2020
Last Update Date: 04/29/2020
Certification Date: 04/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15613 BEL RED RD STE C
BELLEVUE WA
98008-2348
US

IV. Provider business mailing address

15613 BEL RED RD STE C
BELLEVUE WA
98008-2348
US

V. Phone/Fax

Practice location:
  • Phone: 425-869-7560
  • Fax:
Mailing address:
  • Phone: 425-869-7560
  • Fax: 425-869-7699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. XUE DU
Title or Position: GENERAL DENTIST
Credential: DDS
Phone: 323-873-6690