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General NPI Number Information
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NPI Number | 1790947778
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Entity Type | Organization
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Legal Business Name | PEDIATRIC DENTAL CARE CENTER
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Dates
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Enumeration Date | 06/30/2008
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Last Update Date | 06/30/2008
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Provider Practice Location Address
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Address Line | 316 MARTIN LUTHER KING JR WAY STE 209
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City | TACOMA
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State | WA
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Zip | 98405-4254
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Country | US
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Telephone | 253-627-6023
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Fax | 253-627-4035
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Provider Business Mailing Address
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Address Line | 316 MARTIN LUTHER KING JR WAY STE 209
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City | TACOMA
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State | WA
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Zip | 98405-4254
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Country | US
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Telephone | 253-627-6023
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Fax | 253-627-4035
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. JOHN L. GIBBONS
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Credential | D.M.D.
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Telephone | 253-627-6023
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | DE05994
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License Number State | WA
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