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General NPI Number Information
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NPI Number | 1164197125
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Entity Type | Organization
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Legal Business Name | FAIRWOOD PEDODONTICSLLC
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Dates
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Enumeration Date | 08/11/2021
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Last Update Date | 08/11/2021
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Provider Practice Location Address
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Address Line | 14246 SE 176TH ST
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City | RENTON
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State | WA
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Zip | 98058-8787
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Country | US
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Telephone | 425-523-1211
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Fax |
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Provider Business Mailing Address
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Address Line | 14246 SE 176TH ST
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City | RENTON
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State | WA
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Zip | 98058-8787
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. TRAVIS PROBST
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Credential |
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Telephone | 253-631-3015
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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