Provider Demographics
NPI:1649694118
Name:GOLDEN YEARS SMILES LLC
Entity type:Organization
Organization Name:GOLDEN YEARS SMILES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KALA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-345-6484
Mailing Address - Street 1:PO BOX 793
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98046-0793
Mailing Address - Country:US
Mailing Address - Phone:425-343-7510
Mailing Address - Fax:
Practice Address - Street 1:22131 OLD OWEN RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-9625
Practice Address - Country:US
Practice Address - Phone:425-345-6484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-04
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00006928124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty