Provider Demographics
NPI:1285944991
Name:PACIFIC NORTHWEST DENTAL
Entity type:Organization
Organization Name:PACIFIC NORTHWEST DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:JEANETTE
Authorized Official - Last Name:MAHONEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:425-339-9999
Mailing Address - Street 1:4367 RUCKER AVENUE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203
Mailing Address - Country:US
Mailing Address - Phone:425-339-9999
Mailing Address - Fax:
Practice Address - Street 1:4367 RUCKER AVENUE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203
Practice Address - Country:US
Practice Address - Phone:425-339-9999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60011791261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental