Provider Demographics
NPI:1285951327
Name:PACIFIC HIGHWAY DENTAL ASSOCIATES
Entity type:Organization
Organization Name:PACIFIC HIGHWAY DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:PAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-529-9434
Mailing Address - Street 1:27020 PACIFIC HWY S
Mailing Address - Street 2:SUITE C
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-6951
Mailing Address - Country:US
Mailing Address - Phone:253-529-9434
Mailing Address - Fax:
Practice Address - Street 1:27020 PACIFIC HWY S
Practice Address - Street 2:SUITE C
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-6951
Practice Address - Country:US
Practice Address - Phone:253-529-9434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-29
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000073051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5022967Medicaid