Healthcare Provider Details

I. General information

NPI: 1437690955
Provider Name (Legal Business Name): SOUTH BEACH DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2017
Last Update Date: 03/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 S MONTESANO ST
WESTPORT WA
98595
US

IV. Provider business mailing address

PO BOX 2049
WESTPORT WA
98595-2049
US

V. Phone/Fax

Practice location:
  • Phone: 360-268-6225
  • Fax: 360-268-6095
Mailing address:
  • Phone: 360-268-6225
  • Fax: 360-268-6095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE008350
License Number StateWA

VIII. Authorized Official

Name: DUANE W PEGG
Title or Position: PRESIDENT
Credential: DMD
Phone: 360-268-6225