Provider Demographics
NPI:1730687781
Name:AUBURN AVENUE DENTAL
Entity type:Organization
Organization Name:AUBURN AVENUE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DIPTI
Authorized Official - Middle Name:
Authorized Official - Last Name:SRIVASTAVA
Authorized Official - Suffix:
Authorized Official - Credentials:DDSA
Authorized Official - Phone:253-833-3680
Mailing Address - Street 1:130 3RD ST NE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-4013
Mailing Address - Country:US
Mailing Address - Phone:253-833-3680
Mailing Address - Fax:253-833-9581
Practice Address - Street 1:130 3RD ST NE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-4013
Practice Address - Country:US
Practice Address - Phone:253-833-3680
Practice Address - Fax:253-833-9581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-24
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60034827261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental