Provider Demographics
NPI:1790247088
Name:DENTURE SERVICES NORTHWEST INC
Entity type:Organization
Organization Name:DENTURE SERVICES NORTHWEST INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-565-4435
Mailing Address - Street 1:6323 111TH ST SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-1303
Mailing Address - Country:US
Mailing Address - Phone:253-565-4435
Mailing Address - Fax:253-565-4661
Practice Address - Street 1:6323 111TH ST SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-1303
Practice Address - Country:US
Practice Address - Phone:253-565-4435
Practice Address - Fax:253-565-4661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-04
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5038252Medicaid