Healthcare Provider Details

I. General information

NPI: 1093147068
Provider Name (Legal Business Name): ETHERIDGE FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2013
Last Update Date: 08/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 E MADISON ST STE 103
SEATTLE WA
98112-4221
US

IV. Provider business mailing address

3130 E MADISON ST STE 103
SEATTLE WA
98112-4221
US

V. Phone/Fax

Practice location:
  • Phone: 206-323-0990
  • Fax:
Mailing address:
  • Phone: 206-323-0990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State

VIII. Authorized Official

Name: LORI LIU
Title or Position: OFFICE MANAGER
Credential:
Phone: 206-323-0990