Provider Demographics
NPI:1962933150
Name:EDWARD IM DDS PS
Entity type:Organization
Organization Name:EDWARD IM DDS PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:IM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-450-9500
Mailing Address - Street 1:1200 112TH AVE NE
Mailing Address - Street 2:C222
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3732
Mailing Address - Country:US
Mailing Address - Phone:425-450-9500
Mailing Address - Fax:425-450-5008
Practice Address - Street 1:1200 112TH AVE NE
Practice Address - Street 2:C222
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3732
Practice Address - Country:US
Practice Address - Phone:425-450-9500
Practice Address - Fax:425-450-5008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA122300000X, 1223P0300X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty