=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003562026
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LENA FUSA OGIWARA DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2022
-----------------------------------------------------
Last Update Date | 01/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3100 NW BUCKLIN HILL RD STE 202
-----------------------------------------------------
City | SILVERDALE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98383-8362
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-377-3776
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2533 STEPHENSON AVE
-----------------------------------------------------
City | BREMERTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98310-2630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DE61405144
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------