Healthcare Provider Details

I. General information

NPI: 1457896847
Provider Name (Legal Business Name): TREE HOUSE DENTISTRY FOR KIDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2016
Last Update Date: 12/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20214 BALLINGER WAY NE
SHORELINE WA
98155-1144
US

IV. Provider business mailing address

20214 BALLINGER WAY NE
SHORELINE WA
98155-1144
US

V. Phone/Fax

Practice location:
  • Phone: 206-466-6250
  • Fax:
Mailing address:
  • Phone: 206-466-6250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60377097
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License NumberGA60407769
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE60384474
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDE60377097
License Number StateWA

VIII. Authorized Official

Name: DR. MICHAEL BENJAMINE AUSTIN
Title or Position: MEMBER
Credential: DMD
Phone: 801-550-4702