Provider Demographics
NPI:1447657382
Name:SMILE BRIGHT DENTURE CENTER BALLARD INC.
Entity type:Organization
Organization Name:SMILE BRIGHT DENTURE CENTER BALLARD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTURIST / PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DUNG
Authorized Official - Middle Name:Q
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LD
Authorized Official - Phone:206-782-5253
Mailing Address - Street 1:315 E CASINO RD STE B
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-1846
Mailing Address - Country:US
Mailing Address - Phone:425-355-4409
Mailing Address - Fax:
Practice Address - Street 1:8541 15TH AVE NW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98117-3606
Practice Address - Country:US
Practice Address - Phone:206-782-5253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN 00000360122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty