1932420650 NPI number — YELM FAMILY DENTISTRY

Table of content: (NPI 1932420650)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932420650 NPI number — YELM FAMILY DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
YELM FAMILY DENTISTRY
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:
1932420650
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5350
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YELM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98597-5350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-458-1919
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 PLAZA DR SE
Provider Second Line Business Practice Location Address:
BLDG A, SUITE 1
Provider Business Practice Location Address City Name:
YELM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98597-8798
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-458-1919
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/16/2010

Additional Information

Authorized Official

Authorized Official Last Name:
RAKOW
Authorized Official First Name:
CLISTA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
360-458-1919

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  7336 , 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: 5029046 . This is a "STATE PROVIDER NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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