1760655716 NPI number — CONDON DENTAL SERVICES PS INC

Table of content: (NPI 1760655716)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760655716 NPI number — CONDON DENTAL SERVICES PS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONDON DENTAL SERVICES PS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NORTHWEST DENTAL SERVICES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760655716
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5901 N LIDGERWOOD
Provider Second Line Business Mailing Address:
SUITE 233
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-489-4763
Provider Business Mailing Address Fax Number:
509-489-4767

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5901 N LIDGERWOOD
Provider Second Line Business Practice Location Address:
SUITE 233
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-489-4763
Provider Business Practice Location Address Fax Number:
509-489-4767
Provider Enumeration Date:
04/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CONDON
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
P
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
509-926-5272

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5055512 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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