Provider Demographics
NPI:1235211673
Name:FAMILY HEALTH CENTERS DENTAL
Entity Type:Organization
Organization Name:FAMILY HEALTH CENTERS DENTAL
Other - Org Name:OKANOGAN FARM WORKERS CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-422-5700
Mailing Address - Street 1:PO BOX 1340
Mailing Address - Street 2:
Mailing Address - City:OKANOGAN
Mailing Address - State:WA
Mailing Address - Zip Code:98840-1340
Mailing Address - Country:US
Mailing Address - Phone:509-422-5700
Mailing Address - Fax:509-422-7680
Practice Address - Street 1:626 SECOND AVE S
Practice Address - Street 2:
Practice Address - City:OKANOGAN
Practice Address - State:WA
Practice Address - Zip Code:98840-9679
Practice Address - Country:US
Practice Address - Phone:509-422-6705
Practice Address - Fax:509-422-6708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600625131261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5022199Medicaid
WA941000Medicare Oscar/Certification