Provider Demographics
NPI:1043591043
Name:LAVINCE GROUP PS
Entity Type:Organization
Organization Name:LAVINCE GROUP PS
Other - Org Name:YELM PRAIRIE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:SHUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-458-7645
Mailing Address - Street 1:PO BOX 1568
Mailing Address - Street 2:
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597-1568
Mailing Address - Country:US
Mailing Address - Phone:360-458-7645
Mailing Address - Fax:360-458-2745
Practice Address - Street 1:202 FIRST STREET SOUTH,
Practice Address - Street 2:
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597
Practice Address - Country:US
Practice Address - Phone:360-458-7645
Practice Address - Fax:360-458-2745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-02
Last Update Date:2011-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00006408261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental