Provider Demographics
NPI:1124375126
Name:HALF DENTAL WA
Entity Type:Organization
Organization Name:HALF DENTAL WA
Other - Org Name:HALF DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:L
Authorized Official - Last Name:RENNELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-694-4253
Mailing Address - Street 1:910 NE MINNEHAHA
Mailing Address - Street 2:SUITE 12
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98665
Mailing Address - Country:US
Mailing Address - Phone:360-694-4253
Mailing Address - Fax:360-695-3589
Practice Address - Street 1:910 NE MINNEHAHA ST
Practice Address - Street 2:SUITE 12
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-8750
Practice Address - Country:US
Practice Address - Phone:360-694-4253
Practice Address - Fax:360-695-3589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-08
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60096080122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty