# CHC OF SNOHOMISH COUNTY 112TH DENTAL

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1649460288
- **Authorized official:** MR. KENNETH M GREEN (EXECUTIVE DIRECTOR)
- **Authorized official phone:** (425) 789-3700

## Contact information

- **Practice address:** 1019 112TH ST SW, EVERETT, WA 98204
- **Practice address phone:** (425) 551-6001
- **Practice address fax:** (425) 551-6008
- **Mailing address:** PO BOX 13060, EVERETT, WA 98206-3060
- **Mailing address phone:** (425) 789-3700
- **Mailing address fax:** (425) 789-3754

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | 5010921 | WA | Yes |

## Other

- **Enumeration date:** 07/30/2007
- **Last updated:** 07/30/2007

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 5010921 | — | WA |