=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184135881
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVIVE SMILES DENTISTRY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2017
-----------------------------------------------------
Last Update Date | 03/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 259 YALE AVE N
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98109-5430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-829-8565
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 259 YALE AVE N
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98109-5430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-829-8565
-----------------------------------------------------
Fax | 206-739-5797
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DDS
-----------------------------------------------------
Name | DR. BILL S WONG
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 206-829-8565
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 9084
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------