| Organization Name: | FRED EBSWORTH DDS PS |
| NPI Number: | 1104061969 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | CHARLES F EBSWORTH (PRESIDENT) |
| Mailing Address: | 17191 Bothell Way Ne Suite 201 Lake Forest Park |
| State: | WA US |
| Postal Code: | 981555534 |
| Phone Number: | 2063620152 |
| Fax Number: | 2063653441 |
| NPI Enumeration Date: | 12/09/2008 |
| NPI Last Update Date: | 12/09/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QD0000X |
| License Number: | DE00004073 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WA |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Dental |
| Taxonomy Definition: | |