Provider Demographics
NPI:1750409827
Name:OLYMPIC DENTAL & DENTURE CENTER,LLC
Entity type:Organization
Organization Name:OLYMPIC DENTAL & DENTURE CENTER,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LD
Authorized Official - Phone:253-752-1320
Mailing Address - Street 1:3720 6TH AVE STE A
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98406-4938
Mailing Address - Country:US
Mailing Address - Phone:253-752-1320
Mailing Address - Fax:253-752-1425
Practice Address - Street 1:3720 6TH AVE STE A
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-4938
Practice Address - Country:US
Practice Address - Phone:253-752-1320
Practice Address - Fax:253-752-1425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2050411OtherUNITED CONCORDIA
WA5056817Medicaid