Provider Demographics
NPI:1104061969
Name:FRED EBSWORTH DDS PS
Entity type:Organization
Organization Name:FRED EBSWORTH DDS PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:F
Authorized Official - Last Name:EBSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:206-362-0152
Mailing Address - Street 1:17191 BOTHELL WAY NE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAKE FOREST PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98155-5534
Mailing Address - Country:US
Mailing Address - Phone:206-362-0152
Mailing Address - Fax:206-365-3441
Practice Address - Street 1:17191 BOTHELL WAY NE
Practice Address - Street 2:SUITE 201
Practice Address - City:LAKE FOREST PARK
Practice Address - State:WA
Practice Address - Zip Code:98155-5534
Practice Address - Country:US
Practice Address - Phone:206-362-0152
Practice Address - Fax:206-365-3441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00004073261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental