=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598279747
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHINN KIDS DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2017
-----------------------------------------------------
Last Update Date | 05/01/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5122 OLYMPIC DR NW STE A101
-----------------------------------------------------
City | GIG HARBOR
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98335-1768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-649-0181
-----------------------------------------------------
Fax | 253-313-5892
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5122 OLYMPIC DR NW #A-101
-----------------------------------------------------
City | GIG HARBOR
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98335-1767
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-649-0181
-----------------------------------------------------
Fax | 253-313-5892
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | VICKI EDWARDS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 253-649-0181
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------