Provider Demographics
NPI:1730451527
Name:ALPHA DENTURE CLINIC, INC
Entity type:Organization
Organization Name:ALPHA DENTURE CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-658-0256
Mailing Address - Street 1:1242 STATE AVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-3672
Mailing Address - Country:US
Mailing Address - Phone:360-658-0256
Mailing Address - Fax:360-658-7280
Practice Address - Street 1:1242 STATE AVE
Practice Address - Street 2:SUITE G
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-3672
Practice Address - Country:US
Practice Address - Phone:360-658-0256
Practice Address - Fax:360-658-7280
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALPHA DENTURE CLINIC, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN000021302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization