Provider Demographics
NPI:1083980080
Name:KALISPEL TRIBE OF INDIANS
Entity Type:Organization
Organization Name:KALISPEL TRIBE OF INDIANS
Other - Org Name:CAMAS CENTER DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AM
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BIRDTAIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-447-7112
Mailing Address - Street 1:PO BOX 67
Mailing Address - Street 2:
Mailing Address - City:USK
Mailing Address - State:WA
Mailing Address - Zip Code:99180-0067
Mailing Address - Country:US
Mailing Address - Phone:509-447-7111
Mailing Address - Fax:509-445-1152
Practice Address - Street 1:1821 LECLERC RD N STE 1
Practice Address - Street 2:
Practice Address - City:CUSICK
Practice Address - State:WA
Practice Address - Zip Code:99119-5015
Practice Address - Country:US
Practice Address - Phone:509-447-7111
Practice Address - Fax:509-445-1152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-24
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00009801122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5051537Medicaid