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General NPI Number Information
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NPI Number | 1376647743
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Entity Type | Organization
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Legal Business Name | COSTA & DAGEENAKIS FAMILY DENTISTRY PLLC
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Dates
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Enumeration Date | 09/07/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1565 WOODRIDGE DR SE STE A
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City | PORT ORCHARD
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State | WA
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Zip | 98366
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Country | US
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Telephone | 360-876-0550
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Fax | 360-876-0861
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Provider Business Mailing Address
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Address Line | 1565 WOODRIDGE DR SE STE A
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City | PORT ORCHARD
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State | WA
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Zip | 98366
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Country | US
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Telephone | 360-876-0550
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Fax | 360-876-0861
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Authorized Official
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Title or Position | TREATMENT COORDINATOR
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Name | MRS. MICHELLE D RICHARDSON
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Credential |
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Telephone | 360-876-0550
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 7181
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DE00009872
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License Number State | WA
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 9302
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License Number State | WA
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