Provider Demographics
NPI:1104147057
Name:CHRISTINE M TWEEDY DDS MSD PS
Entity type:Organization
Organization Name:CHRISTINE M TWEEDY DDS MSD PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:TWEEDY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MSD
Authorized Official - Phone:206-937-6481
Mailing Address - Street 1:4520 42ND AVE SW
Mailing Address - Street 2:#24
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-4240
Mailing Address - Country:US
Mailing Address - Phone:206-937-6481
Mailing Address - Fax:206-937-7043
Practice Address - Street 1:4520 42ND AVE SW
Practice Address - Street 2:#24
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-4240
Practice Address - Country:US
Practice Address - Phone:206-937-6481
Practice Address - Fax:206-937-7043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA83591223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5031596Medicaid