1043394828 NPI number — THE KIDDS PLACE, DENTISTRY FOR CHILDREN, P.S.

Table of content: (NPI 1043394828)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043394828 NPI number — THE KIDDS PLACE, DENTISTRY FOR CHILDREN, P.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE KIDDS PLACE, DENTISTRY FOR CHILDREN, 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:
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:
1043394828
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:
506 E HASTINGS RD
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99218-1900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-252-4746
Provider Business Mailing Address Fax Number:
509-789-1640

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
506 E HASTINGS RD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99218-1900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-252-4746
Provider Business Practice Location Address Fax Number:
509-789-1640
Provider Enumeration Date:
10/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EVANS
Authorized Official First Name:
JARED
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
509-252-4746

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DE00006525 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1223P0221X , with the licence number: DE00010191 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 5010848 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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