Healthcare Provider Details

I. General information

NPI: 1760695282
Provider Name (Legal Business Name): NORTHSHORE DENTAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18404 104TH AVE NE
BOTHELL WA
98011-3414
US

IV. Provider business mailing address

18404 104TH AVE NE
BOTHELL WA
98011-3414
US

V. Phone/Fax

Practice location:
  • Phone: 425-486-2422
  • Fax: 425-486-2712
Mailing address:
  • Phone: 425-241-2960
  • Fax: 425-486-2712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE00007951
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DIANE VO
Title or Position: OWNER
Credential: DDS
Phone: 425-785-8305