1720458359 NPI number — ELLIS BURKE JARDINE, DMD, PC

Table of content: (NPI 1720458359)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720458359 NPI number — ELLIS BURKE JARDINE, DMD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELLIS BURKE JARDINE, DMD, PC
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:
1720458359
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
406 SE 131ST AVE STE 305
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:
98683-4014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-253-9792
Provider Business Mailing Address Fax Number:
360-604-5266

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
406 SE 131ST AVE STE 305
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:
98683-4014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-253-9792
Provider Business Practice Location Address Fax Number:
360-604-5266
Provider Enumeration Date:
09/24/2015

Additional Information

Authorized Official

Authorized Official Last Name:
JARDINE
Authorized Official First Name:
ELLIS
Authorized Official Middle Name:
BURKE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
360-253-9792

Provider Taxonomy Codes

  • Taxonomy code: 1223P0700X , with the licence number:  60339865 , 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: WA 60339865 . This is a "WA DENTAL LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com