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General NPI Number Information
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NPI Number | 1619308137
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Entity Type | Organization
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Legal Business Name | FEDERAL WAY DENTAL LLC
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Dates
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Enumeration Date | 12/09/2013
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Last Update Date | 12/09/2013
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Provider Practice Location Address
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Address Line | 31401 PACIFIC HWY S
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City | FEDERAL WAY
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State | WA
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Zip | 98003-5403
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Country | US
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Telephone | 253-839-1007
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Fax | 253-839-4035
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Provider Business Mailing Address
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Address Line | 31401 PACIFIC HWY S
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City | FEDERAL WAY
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State | WA
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Zip | 98003-5403
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Country | US
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Telephone | 253-839-1007
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Fax | 253-839-4035
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Authorized Official
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Title or Position | DENTIST
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Name | NANDITA LILLY
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Credential |
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Telephone | 253-839-1007
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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 | DE60398437
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License Number State | WA
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