Provider Demographics
NPI:1902078421
Name:SPECKHARDTS DENTAL LAB INC
Entity Type:Organization
Organization Name:SPECKHARDTS DENTAL LAB INC
Other - Org Name:DENTURE & DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:T
Authorized Official - Last Name:SPECKHARDT
Authorized Official - Suffix:
Authorized Official - Credentials:LD
Authorized Official - Phone:253-845-7001
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371
Mailing Address - Country:US
Mailing Address - Phone:253-845-7001
Mailing Address - Fax:253-770-6212
Practice Address - Street 1:219 4TH AVE SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372
Practice Address - Country:US
Practice Address - Phone:253-845-7001
Practice Address - Fax:253-770-6212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000132122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty