Healthcare Provider Details

I. General information

NPI: 1588805626
Provider Name (Legal Business Name): WESTSIDE SMILE DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2009
Last Update Date: 03/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9670 14TH AVE SW UNIT AB
SEATTLE WA
98106-2876
US

IV. Provider business mailing address

9670 14TH AVE SW UNIT AB
SEATTLE WA
98106-2876
US

V. Phone/Fax

Practice location:
  • Phone: 206-762-7222
  • Fax: 206-762-7783
Mailing address:
  • Phone: 206-762-7222
  • Fax: 206-762-7783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberDN327
License Number StateWA

VIII. Authorized Official

Name: PHONG ANH VONG
Title or Position: DENTURIST
Credential: LD
Phone: 206-762-7222