1447630116 NPI number — THOMAS HENRY DDS PS DBA CANYON ORTHODONTICS

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 1447630116 NPI number — THOMAS HENRY DDS PS DBA CANYON ORTHODONTICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THOMAS HENRY DDS PS DBA CANYON ORTHODONTICS
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:
1447630116
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5620 112TH ST E
Provider Second Line Business Mailing Address:
SUITE 255
Provider Business Mailing Address City Name:
PUYALLUP
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98373-3206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-256-4000
Provider Business Mailing Address Fax Number:
253-770-9638

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5620 112TH ST E
Provider Second Line Business Practice Location Address:
SUITE 255
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98373-3206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-256-4000
Provider Business Practice Location Address Fax Number:
253-770-9638
Provider Enumeration Date:
06/08/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HENRY
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/DENTIST
Authorized Official Telephone Number:
253-256-4000

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  5432 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X , with the licence number: 10731 , 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)