Provider Demographics
NPI:1164042040
Name:MOUNTLAKE FAMILY DENTISTRY
Entity type:Organization
Organization Name:MOUNTLAKE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALYSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-412-3955
Mailing Address - Street 1:22725 44TH AVE W STE 100
Mailing Address - Street 2:
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-4583
Mailing Address - Country:US
Mailing Address - Phone:425-412-3955
Mailing Address - Fax:
Practice Address - Street 1:22725 44TH AVE W STE 100
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-4583
Practice Address - Country:US
Practice Address - Phone:425-412-3955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty