MEDICARE: HARBOR KIDS DENTAL & ORTHODONTICS OF TACOMA PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DE60282727	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DE60282727	OTHER	WA	DENTAL LICENSE

General Provider Information

NPI Number	:	1639536097
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HARBOR KIDS DENTAL & ORTHODONTICS OF TACOMA PC

Provider Business Mailing Address
First Line	:	4002 S M ST
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98418-3800
Country	:	US
Telephone Number	:	253-474-0606
Fax Number	:	253-537-5438

Provider Business Practice Location Address
First Line	:	4002 S M ST
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98418-3800
Country	:	US
Telephone Number	:	253-474-0606
Fax Number	:	253-537-5438

Authorized Official
Title or Position	:	OWNER
Name	:	JUSTIN L VANBIBBER
Credential	:	DMD
Telephone Number	:	253-537-5437

Provider Enumeration Date	:	01/15/2016
Last Update Date	:	01/15/2016

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