Healthcare Provider Details

I. General information

NPI: 1568981470
Provider Name (Legal Business Name): SEA MAR SPECIALTY DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 116TH AVE NE
BELLEVUE WA
98004-3047
US

IV. Provider business mailing address

1040 S HENDERSON ST
SEATTLE WA
98108-4720
US

V. Phone/Fax

Practice location:
  • Phone: 425-998-5090
  • Fax: 425-998-5099
Mailing address:
  • Phone: 206-763-5277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: KRISTINA HOESCHEN
Title or Position: ADMINISTRATION DIRECTOR
Credential: DO
Phone: 206-763-5277