Provider Demographics
NPI:1992059737
Name:PUYALLUP DENTAL, LLC
Entity type:Organization
Organization Name:PUYALLUP DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:PROBST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-475-9120
Mailing Address - Street 1:16420 MERIDIAN E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98375-2514
Mailing Address - Country:US
Mailing Address - Phone:253-475-9120
Mailing Address - Fax:253-475-9284
Practice Address - Street 1:16420 MERIDIAN E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98375-2514
Practice Address - Country:US
Practice Address - Phone:253-475-9120
Practice Address - Fax:253-475-9284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 60198294122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty