=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346492246
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANTHONY DIRE, D.D.S.,P.S.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2008
-----------------------------------------------------
Last Update Date | 10/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 411 STRANDER BLVD SUITE 206
-----------------------------------------------------
City | TUKWILA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98188-2935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-575-1125
-----------------------------------------------------
Fax | 206-575-2825
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 411 STRANDER BLVD SUITE 206
-----------------------------------------------------
City | TUKWILA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98188-2935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-575-1125
-----------------------------------------------------
Fax | 206-575-2825
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANGAGER
-----------------------------------------------------
Name | JENNIFER STAHL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 206-575-1125
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------