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General NPI Number Information
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NPI Number | 1386973964
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Entity Type | Organization
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Legal Business Name | ST. ANTHONY'S FAMILY DENTISTRY, LLC
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Dates
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Enumeration Date | 12/10/2009
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Last Update Date | 12/10/2009
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Provider Practice Location Address
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Address Line | 11511 CANTERWOOD BLVD NW STE. 120
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City | GIG HARBOR
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State | WA
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Zip | 98332-5813
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Country | US
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Telephone | 253-857-2483
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Fax |
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Provider Business Mailing Address
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Address Line | 11511 CANTERWOOD BLVD NW STE. 120
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City | GIG HARBOR
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State | WA
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Zip | 98332-5813
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Country | US
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Telephone | 253-857-2483
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARK D. JOHNSON
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Credential | DDS
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Telephone | 253-857-2483
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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 | 5841
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License Number State | WA
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