Provider Demographics
NPI:1962754762
Name:THERON MANSON DDS PS
Entity type:Organization
Organization Name:THERON MANSON DDS PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THERON
Authorized Official - Middle Name:ANGUS
Authorized Official - Last Name:MANSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-823-1909
Mailing Address - Street 1:9750 NE 120TH PL #8
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-4207
Mailing Address - Country:US
Mailing Address - Phone:425-823-1909
Mailing Address - Fax:425-823-8969
Practice Address - Street 1:9750 NE 120TH PL #8
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-4207
Practice Address - Country:US
Practice Address - Phone:425-823-1909
Practice Address - Fax:425-823-8969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-04
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA9434122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty