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General NPI Number Information
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NPI Number | 1295083632
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Entity Type | Organization
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Legal Business Name | JOHN BEACK DMD PS
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Dates
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Enumeration Date | 08/15/2012
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Last Update Date | 08/15/2012
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Provider Practice Location Address
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Address Line | 13210 SE 240TH ST SUITE B1
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City | KENT
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State | WA
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Zip | 98042-5182
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Country | US
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Telephone | 253-631-8490
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Fax |
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Provider Business Mailing Address
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Address Line | 13210 SE 240TH ST SUITE B1
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City | KENT
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State | WA
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Zip | 98042-5182
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Country | US
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Telephone | 253-631-8490
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JOHN BEACK
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Credential |
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Telephone | 425-999-2402
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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 | DE00010948
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License Number State | WA
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