| NPI | 1538613112 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | HEIDI JOHNSON Practice Administrator 360-681-8884 |
| Organization Subpart ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA 5445) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA 10482) |
| Enumeration Date | 2016-08-11 |
| Last Update Date | 2016-08-11 |