Provider Demographics
NPI:1023379633
Name:STUART DENTAL LLC
Entity Type:Organization
Organization Name:STUART DENTAL LLC
Other - Org Name:BLUE MOUNTAIN DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARCY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-525-4662
Mailing Address - Street 1:1545 BUSINESS ONE CIR
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-9526
Mailing Address - Country:US
Mailing Address - Phone:509-525-4662
Mailing Address - Fax:509-525-0513
Practice Address - Street 1:1545 BUSINESS ONE CIR
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-9526
Practice Address - Country:US
Practice Address - Phone:509-525-4662
Practice Address - Fax:509-525-0513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA9646122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty