Provider Demographics
NPI:1093965600
Name:CUSTOM DENTURES LLC
Entity Type:Organization
Organization Name:CUSTOM DENTURES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAMERON
Authorized Official - Middle Name:L
Authorized Official - Last Name:FETTIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-883-9888
Mailing Address - Street 1:13720 NE 28TH ST
Mailing Address - Street 2:#B
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-8048
Mailing Address - Country:US
Mailing Address - Phone:360-883-9888
Mailing Address - Fax:360-883-9909
Practice Address - Street 1:13720 NE 28TH ST
Practice Address - Street 2:#B
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98682-8048
Practice Address - Country:US
Practice Address - Phone:360-883-9888
Practice Address - Fax:360-883-9909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-19
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000393122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5047576Medicaid