1124375126 NPI number — HALF DENTAL WA

Table of content: (NPI 1124375126)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124375126 NPI number — HALF DENTAL WA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HALF DENTAL WA
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:
1124375126
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
910 NE MINNEHAHA
Provider Second Line Business Mailing Address:
SUITE 12
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98665
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-694-4253
Provider Business Mailing Address Fax Number:
360-695-3589

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 NE MINNEHAHA ST
Provider Second Line Business Practice Location Address:
SUITE 12
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98665-8750
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-694-4253
Provider Business Practice Location Address Fax Number:
360-695-3589
Provider Enumeration Date:
08/08/2012

Additional Information

Authorized Official

Authorized Official Last Name:
RENNELS
Authorized Official First Name:
TERESA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
360-694-4253

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DE60096080 , 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)





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