Provider Demographics
NPI:1053654525
Name:ANDREA M. VANCLEAVE, DDS, PLLC
Entity Type:Organization
Organization Name:ANDREA M. VANCLEAVE, DDS, PLLC
Other - Org Name:OLYMPIA PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:VANCLEAVE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-352-3515
Mailing Address - Street 1:2612 YELM HWY SE
Mailing Address - Street 2:SUITE A
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-4826
Mailing Address - Country:US
Mailing Address - Phone:360-352-3515
Mailing Address - Fax:360-352-0158
Practice Address - Street 1:2612 YELM HWY SE
Practice Address - Street 2:SUITE A
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-4826
Practice Address - Country:US
Practice Address - Phone:360-352-3515
Practice Address - Fax:360-352-0158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-02
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE602847241223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty