| Organization Name: | SEDRO WOOLLEY FAMILY DENTAL CENTER, P.S. |
| NPI Number: | 1184963845 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | HANSROLF H GRUENER (OWNER) |
| Mailing Address: | 830 Metcalf St Sedro Woolley |
| State: | WA US |
| Postal Code: | 982841423 |
| Phone Number: | 3608550351 |
| Fax Number: | 3608559357 |
| NPI Enumeration Date: | 01/31/2013 |
| NPI Last Update Date: | 01/31/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QD0000X |
| License Number: | 603264506 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WA |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Dental |
| Taxonomy Definition: | |