Organization
GREAT WALL CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
EPHRAIM ROLLOLAZO (OFFICE MANAGER)
(425) 656-9025
Entity
Organization
Contact information
Practice address
18230 E VALLEY HWY, 168, KENT, WA 98032-1259
(425) 656-9025
Mailing address
18230 E VALLEY HWY, 168, KENT, WA 98032-1259
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
DE00007365
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5034616
DSHS PROVIDER NUMBER
WA
Enumeration date
12/03/2009
Last updated
12/03/2009
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