Provider Demographics
NPI:1548454655
Name:WASHINGTON STATE SMILE PARTNERS
Entity type:Organization
Organization Name:WASHINGTON STATE SMILE PARTNERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:206-909-1365
Mailing Address - Street 1:221 WINSLOW WAY W
Mailing Address - Street 2:302
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-4915
Mailing Address - Country:US
Mailing Address - Phone:206-909-1365
Mailing Address - Fax:
Practice Address - Street 1:221 WINSLOW WAY W
Practice Address - Street 2:302
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-4915
Practice Address - Country:US
Practice Address - Phone:206-909-1365
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-31
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5901111Medicaid