Healthcare Provider Details

I. General information

NPI: 1083304455
Provider Name (Legal Business Name): SALT DENTAL DMD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2023
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 TALBOT RD S STE 105
RENTON WA
98055-6238
US

IV. Provider business mailing address

4300 TALBOT RD S STE 105
RENTON WA
98055-6238
US

V. Phone/Fax

Practice location:
  • Phone: 360-547-3687
  • Fax: 206-703-2817
Mailing address:
  • Phone: 206-395-4748
  • Fax: 206-703-2817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CAM-TU VO
Title or Position: DENTIST
Credential: DMD
Phone: 360-547-3687