# JAY D. DEIGLMEIER DDS. PS

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Panther Lake Dental
- **Organization subpart:** No

## Provider details

- **NPI number:** 1316010531
- **Authorized official:** JAY D DEIGLMEIER DDS (PRESIDENT)
- **Authorized official phone:** (253) 854-1222

## Contact information

- **Practice address:** 10920 SE 208TH ST, KENT, WA 98031-4009
- **Practice address phone:** (253) 854-1222
- **Practice address fax:** (253) 859-1269
- **Mailing address:** 10920 SE 208TH ST, KENT, WA 98031-4009
- **Mailing address phone:** (253) 854-1222

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | DE00007064 | WA | Yes |

## Other

- **Enumeration date:** 11/16/2006
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 103746 | L & I | WA |
| 05 | — | 5023221 | — | WA |
| 05 | — | 5025788 | — | WA |
| 01 | — | 57064 | WDS | WA |
| 01 | — | DE7654 | REGENCE | WA |