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General NPI Number Information
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NPI Number | 1164585634
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Entity Type | Organization
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Legal Business Name | SOUTH SOUND FAMILY DENTISTRY, PLLC
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Dates
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Enumeration Date | 12/18/2006
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Last Update Date | 04/19/2016
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Provider Practice Location Address
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Address Line | 703 LILLY RD NE STE 201
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City | OLYMPIA
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State | WA
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Zip | 98506-5256
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Country | US
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Telephone | 360-459-3400
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Fax |
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Provider Business Mailing Address
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Address Line | 703 LILLY RD NE STE 201
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City | OLYMPIA
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State | WA
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Zip | 98506-5256
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Country | US
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Telephone | 360-459-3400
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LEVI G GREEN
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Credential | DDS
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Telephone | 360-459-3400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DE00009986
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 9986
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License Number State | WA
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