1841202009 NPI number — FALL CITY DENTAL CLINIC INC

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 1841202009 NPI number — FALL CITY DENTAL CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FALL CITY DENTAL CLINIC 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:
Provider Other Organization Name Type Code:
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:
1841202009
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:
PO BOX 1029
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FALL CITY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98024
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-222-7011
Provider Business Mailing Address Fax Number:
425-222-9574

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
33609 REDMOND-FALL CITY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FALL CITY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-222-7011
Provider Business Practice Location Address Fax Number:
425-222-9574
Provider Enumeration Date:
08/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FAWCETT
Authorized Official First Name:
GREG
Authorized Official Middle Name:
M
Authorized Official Title or Position:
DENTIST OWNER PRESIDENT
Authorized Official Telephone Number:
425-222-7011

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DE00005563 , 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: FA1504 . This is a "REGENCE INS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 215712215712 . This is a "PREMERA BLUE CROSS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 674169 . This is a "UNITED CONCORDIA INC" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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