Provider Demographics
NPI:1003021338
Name:SQUAXIN ISLAND DENTAL CLINIC ENCOUNTER
Entity Type:Organization
Organization Name:SQUAXIN ISLAND DENTAL CLINIC ENCOUNTER
Other - Org Name:SQUAXIN ISLAND TRIBE
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WHITNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-427-9006
Mailing Address - Street 1:90 SE KLAH CHE MIN DR
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-9216
Mailing Address - Country:US
Mailing Address - Phone:360-427-9006
Mailing Address - Fax:
Practice Address - Street 1:90 SE KLAH CHE MIN DR
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-9216
Practice Address - Country:US
Practice Address - Phone:360-427-9006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5400122Medicaid