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General NPI Number Information
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NPI Number | 1003148719
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Entity Type | Organization
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Legal Business Name | OLYMPIC DENTAL & DENTURE CENTER, LLC
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Dates
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Enumeration Date | 02/04/2010
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Last Update Date | 02/04/2010
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Provider Practice Location Address
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Address Line | 3720 6TH AVE SUITE A
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City | TACOMA
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State | WA
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Zip | 98406-4938
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Country | US
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Telephone | 253-752-1320
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Fax | 253-752-1425
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Provider Business Mailing Address
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Address Line | 3720 6TH AVE SUITE A
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City | TACOMA
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State | WA
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Zip | 98406-4938
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Country | US
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Telephone | 253-752-1320
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Fax | 253-752-1425
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Authorized Official
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Title or Position | CEO
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Name | RICHARD C JOHNSON
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Credential | L.D,
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Telephone | 253-752-1320
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 416
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License Number State | WA
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