Provider Demographics
NPI:1003117946
Name:MIKHAI C. TA, DDS, PS
Entity Type:Organization
Organization Name:MIKHAI C. TA, DDS, PS
Other - Org Name:CASCADE DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKHAI
Authorized Official - Middle Name:CONG
Authorized Official - Last Name:TA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-936-1803
Mailing Address - Street 1:PO BOX 676
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-0676
Mailing Address - Country:US
Mailing Address - Phone:360-736-5040
Mailing Address - Fax:360-736-1979
Practice Address - Street 1:1211 S GOLD ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-3715
Practice Address - Country:US
Practice Address - Phone:360-736-5040
Practice Address - Fax:360-736-1979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-09
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2000984Medicaid