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General NPI Number Information
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NPI Number | 1245910074
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Entity Type | Organization
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Legal Business Name | STADIUM DENTAL
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Dates
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Enumeration Date | 07/18/2023
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Last Update Date | 07/18/2023
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Provider Practice Location Address
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Address Line | 2 N TACOMA AVE
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City | TACOMA
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State | WA
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Zip | 98403-3125
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Country | US
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Telephone | 253-383-4901
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Fax |
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Provider Business Mailing Address
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Address Line | 2 N TACOMA AVE
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City | TACOMA
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State | WA
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Zip | 98403-3125
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Country | US
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Telephone | 253-383-4901
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Fax | 253-383-0631
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | ANGELA SAMUEL
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Credential |
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Telephone | 253-383-4901
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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 |
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License Number State |
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