Provider Demographics
NPI:1073088423
Name:BONNEY LAKE DENTAL LLC
Entity Type:Organization
Organization Name:BONNEY LAKE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER /DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PROBST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-352-5773
Mailing Address - Street 1:19410 STATE ROUTE 410 E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-8470
Mailing Address - Country:US
Mailing Address - Phone:253-780-7003
Mailing Address - Fax:
Practice Address - Street 1:19410 STATE ROUTE 410 E
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-8470
Practice Address - Country:US
Practice Address - Phone:253-780-7003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1144431529OtherNPI