Provider Demographics
NPI:1316311657
Name:KING SMILE DENTISTRY LLC
Entity type:Organization
Organization Name:KING SMILE DENTISTRY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHU
Authorized Official - Middle Name:THI
Authorized Official - Last Name:BUI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-344-6334
Mailing Address - Street 1:10555 SE 82ND AVE
Mailing Address - Street 2:STE. 105
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-2374
Mailing Address - Country:US
Mailing Address - Phone:503-344-6334
Mailing Address - Fax:
Practice Address - Street 1:10555 SE 82ND AVE
Practice Address - Street 2:STE. 105
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-2374
Practice Address - Country:US
Practice Address - Phone:503-344-6334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-24
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7308122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty