1174617724 NPI number — COLUMBIA ENDODONTIC GROUP, P.S.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174617724 NPI number — COLUMBIA ENDODONTIC GROUP, P.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLUMBIA ENDODONTIC GROUP, P.S.
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:
Provider Other Organization Name Type Code:
6
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:
1174617724
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5015 NE ST. JOHNS ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98661
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-699-1101
Provider Business Mailing Address Fax Number:
360-695-3152

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5015 NE ST. JOHNS ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-699-1101
Provider Business Practice Location Address Fax Number:
360-695-3152
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KOSA
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
AKIO
Authorized Official Title or Position:
TREASURER
Authorized Official Telephone Number:
360-699-1101

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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