Provider Demographics
NPI:1447530399
Name:TULALIP TRIBES OF WASHINGTON
Entity type:Organization
Organization Name:TULALIP TRIBES OF WASHINGTON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:KINSLOW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-716-4511
Mailing Address - Street 1:6406 MARINE DR STE A
Mailing Address - Street 2:
Mailing Address - City:TULALIP
Mailing Address - State:WA
Mailing Address - Zip Code:98271
Mailing Address - Country:US
Mailing Address - Phone:360-716-5800
Mailing Address - Fax:360-716-5789
Practice Address - Street 1:7520 TOTEM BEACH RD
Practice Address - Street 2:
Practice Address - City:TULALIP
Practice Address - State:WA
Practice Address - Zip Code:98271
Practice Address - Country:US
Practice Address - Phone:360-716-4511
Practice Address - Fax:360-716-5789
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TULALIP TRIBES OF WA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-24
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00010342122300000X
WADE00007477122300000X
WADE60104988122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2014972Medicaid