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General NPI Number Information
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NPI Number | 1689188336
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Entity Type | Organization
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Legal Business Name | MEADOWDALE DENTAL CENTER
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Dates
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Enumeration Date | 11/16/2017
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Last Update Date | 11/16/2017
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Provider Practice Location Address
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Address Line | 7500 OLD MILITARY RD NE STE 201
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City | BREMERTON
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State | WA
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Zip | 98311-3242
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Country | US
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Telephone | 360-692-4705
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Fax | 360-692-4846
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Provider Business Mailing Address
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Address Line | 7500 OLD MILITARY RD NE STE 201
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City | BREMERTON
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State | WA
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Zip | 98311-3242
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Country | US
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Telephone | 360-692-4705
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Fax | 360-692-4846
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Authorized Official
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Title or Position | DENTIST
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Name | DAWN M DIVANO
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Credential | DDS
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Telephone | 360-692-4705
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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 | DR00010155
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License Number State | WA
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