Provider Demographics
NPI:1851459069
Name:LILLY DENTURE CENTER, INC
Entity type:Organization
Organization Name:LILLY DENTURE CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTURIST
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:M
Authorized Official - Last Name:CARBONE
Authorized Official - Suffix:
Authorized Official - Credentials:DPD
Authorized Official - Phone:360-412-0812
Mailing Address - Street 1:200 LILLY RD NE STE A
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5080
Mailing Address - Country:US
Mailing Address - Phone:360-412-0812
Mailing Address - Fax:360-412-0814
Practice Address - Street 1:200 LILLY RD NE STE A
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5080
Practice Address - Country:US
Practice Address - Phone:360-412-0812
Practice Address - Fax:360-412-0814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000194122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty