Provider Demographics
NPI:1124234216
Name:MERIDIAN DENTAL CLINIC, LLC
Entity type:Organization
Organization Name:MERIDIAN DENTAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:V
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-852-3033
Mailing Address - Street 1:422 E SMITH ST
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-4546
Mailing Address - Country:US
Mailing Address - Phone:253-852-3033
Mailing Address - Fax:
Practice Address - Street 1:422 E SMITH ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-4546
Practice Address - Country:US
Practice Address - Phone:253-852-3033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty