Provider Demographics
NPI:1033347950
Name:HOUSE, LEE, MAST, MCDONALD AND NELSON, PC
Entity Type:Organization
Organization Name:HOUSE, LEE, MAST, MCDONALD AND NELSON, PC
Other - Org Name:ADVANCED PEDIATRIC DENTISTRY AND ORTHODONTICS OF PASCO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELLISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:RENNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-667-4145
Mailing Address - Street 1:7425 WRIGLEY DRIVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-9999
Mailing Address - Country:US
Mailing Address - Phone:509-543-4948
Mailing Address - Fax:509-543-6940
Practice Address - Street 1:7425 WRIGLEY DRIVE
Practice Address - Street 2:SUITE 201
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-9999
Practice Address - Country:US
Practice Address - Phone:509-543-4948
Practice Address - Fax:509-543-6940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-30
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60203055122300000X, 1223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty