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General NPI Number Information
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NPI Number | 1700148152
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Entity Type | Organization
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Legal Business Name | MOBILE DENTAL NORTHWEST, LLC
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Dates
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Enumeration Date | 06/12/2012
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Last Update Date | 06/12/2012
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Provider Practice Location Address
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Address Line | 1622 S MILDRED ST SUITE B
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City | TACOMA
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State | WA
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Zip | 98465-1610
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Country | US
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Telephone | 253-432-4795
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Fax |
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Provider Business Mailing Address
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Address Line | 1622 S MILDRED ST SUITE B
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City | TACOMA
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State | WA
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Zip | 98465-1610
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Country | US
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Telephone | 253-432-4795
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Fax |
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Authorized Official
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Title or Position | VICE PRESIDENT- FINANCE
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Name | DR. GREGORY ROBERT FISHER
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Credential | DDS
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Telephone | 253-432-4795
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 4923
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License Number State | WA
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