Healthcare Provider Details

I. General information

NPI: 1548605819
Provider Name (Legal Business Name): ANTONIO'S DENTURE SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 05/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 WHEATON WAY #206
BREMERTON WA
98310-3440
US

IV. Provider business mailing address

2817 WHEATON WAY #206
BREMERTON WA
98310-3440
US

V. Phone/Fax

Practice location:
  • Phone: 360-627-7751
  • Fax:
Mailing address:
  • Phone: 360-627-7751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberDN00000366
License Number StateWA

VIII. Authorized Official

Name: RENATO ANTONIO
Title or Position: PRESIDENT
Credential:
Phone: 360-627-7751