Provider Demographics
NPI:1487974341
Name:SOUTH SOUND DENTURES, P.S.
Entity type:Organization
Organization Name:SOUTH SOUND DENTURES, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DH
Authorized Official - Phone:360-709-9909
Mailing Address - Street 1:1822 BLACK LAKE BLVD SW STE 101
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98512-5628
Mailing Address - Country:US
Mailing Address - Phone:360-709-9909
Mailing Address - Fax:
Practice Address - Street 1:1822 BLACK LAKE BLVD. SW SUITE 101
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98512
Practice Address - Country:US
Practice Address - Phone:360-709-9909
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-02
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE10844122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty