Healthcare Provider Details

I. General information

NPI: 1013472687
Provider Name (Legal Business Name): GREAT SMILE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2019
Last Update Date: 02/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26425 NE ALLEN ST STE 102
DUVALL WA
98019-8628
US

IV. Provider business mailing address

26425 NE ALLEN ST STE 102
DUVALL WA
98019-8628
US

V. Phone/Fax

Practice location:
  • Phone: 425-788-1551
  • Fax:
Mailing address:
  • Phone: 425-788-1551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHELSEA D MORTELL
Title or Position: DENTIST/OWNER
Credential: DMD
Phone: 425-788-1551