Provider Demographics
NPI:1194898379
Name:NORTHWEST INSTITUTE OF COSMETIC DENTISTRY
Entity type:Organization
Organization Name:NORTHWEST INSTITUTE OF COSMETIC DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:DER OVANESSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-643-7100
Mailing Address - Street 1:15710 NE 24TH STREET
Mailing Address - Street 2:#B
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98008
Mailing Address - Country:US
Mailing Address - Phone:425-643-7100
Mailing Address - Fax:425-644-1426
Practice Address - Street 1:15710 NE 24TH STREET
Practice Address - Street 2:#B
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98008
Practice Address - Country:US
Practice Address - Phone:425-643-7100
Practice Address - Fax:425-644-1426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA7600122300000X
CA39144122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5034913Medicaid