Provider Demographics
NPI:1154617942
Name:NORTH LAKEWOOD DENTAL PLCC
Entity type:Organization
Organization Name:NORTH LAKEWOOD DENTAL PLCC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PROBST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-475-9120
Mailing Address - Street 1:5422 74TH ST W
Mailing Address - Street 2:SUITE B & C
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-7900
Mailing Address - Country:US
Mailing Address - Phone:253-475-9120
Mailing Address - Fax:253-475-9284
Practice Address - Street 1:5422 74TH ST W
Practice Address - Street 2:SUITE B & C
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-7900
Practice Address - Country:US
Practice Address - Phone:253-475-9120
Practice Address - Fax:253-475-9284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-21
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 60198294122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty