Provider Demographics
NPI:1386781250
Name:ANZI DENTAL CENTER 1
Entity type:Organization
Organization Name:ANZI DENTAL CENTER 1
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAHER(CORPORATE OFFICE)
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:CORTESI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-671-9966
Mailing Address - Street 1:3711 PACIFIC AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98418
Mailing Address - Country:US
Mailing Address - Phone:253-671-9966
Mailing Address - Fax:253-471-3540
Practice Address - Street 1:3711 PACIFIC AVE
Practice Address - Street 2:STE 300
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418
Practice Address - Country:US
Practice Address - Phone:253-671-9966
Practice Address - Fax:253-471-3540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00008264122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5036983Medicaid