Provider Demographics
NPI:1568803146
Name:THE MOBILE TOOTH FAIRY P.S.
Entity type:Organization
Organization Name:THE MOBILE TOOTH FAIRY P.S.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:FINK
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:253-444-7112
Mailing Address - Street 1:6610 89TH STREET CT E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-6222
Mailing Address - Country:US
Mailing Address - Phone:253-444-7112
Mailing Address - Fax:
Practice Address - Street 1:6610 89TH STREET CT E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-6222
Practice Address - Country:US
Practice Address - Phone:253-444-7112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-11
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
No261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1447592381OtherNPI