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General NPI Number Information
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NPI Number | 1932279304
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Entity Type | Organization
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Legal Business Name | MT SI DENTAL CENTER
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Dates
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Enumeration Date | 11/09/2006
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Last Update Date | 06/19/2008
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Provider Practice Location Address
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Address Line | 208 MAIN AVE S
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City | NORTH BEND
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State | WA
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Zip | 98045-8258
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Country | US
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Telephone | 425-888-6522
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1099
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City | NORTH BEND
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State | WA
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Zip | 98045-1099
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Country | US
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Telephone | 425-888-6522
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Fax | 425-888-6526
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Authorized Official
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Title or Position | DENTIST
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Name | DR. KRIS W BRAIN
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Credential | D.D.S
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Telephone | 425-888-6522
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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 | 7403
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License Number State | WA
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