Provider Demographics
NPI:1386973964
Name:ST. ANTHONY'S FAMILY DENTISTRY, LLC
Entity type:Organization
Organization Name:ST. ANTHONY'S FAMILY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-857-2483
Mailing Address - Street 1:11511 CANTERWOOD BLVD NW
Mailing Address - Street 2:STE. 120
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98332-5813
Mailing Address - Country:US
Mailing Address - Phone:253-857-2483
Mailing Address - Fax:
Practice Address - Street 1:11511 CANTERWOOD BLVD NW
Practice Address - Street 2:STE. 120
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98332-5813
Practice Address - Country:US
Practice Address - Phone:253-857-2483
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-10
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA5841122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty