Provider Demographics
NPI:1245378389
Name:WHITE SWAN DENTAL CLNIC
Entity Type:Organization
Organization Name:WHITE SWAN DENTAL CLNIC
Other - Org Name:IHS YAKAMA SERVICE UNIT
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-865-2102
Mailing Address - Street 1:PO BOX 693
Mailing Address - Street 2:
Mailing Address - City:WHITE SWAN
Mailing Address - State:WA
Mailing Address - Zip Code:87841
Mailing Address - Country:US
Mailing Address - Phone:509-865-2102
Mailing Address - Fax:509-865-4986
Practice Address - Street 1:62 BIRD SONG LANE
Practice Address - Street 2:
Practice Address - City:WHITE SWAN
Practice Address - State:WA
Practice Address - Zip Code:98952
Practice Address - Country:US
Practice Address - Phone:509-874-2028
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHITE SWAN DENTAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7100506Medicaid
WA21940OtherLABOR & INDSTRY MED #
WA51239OtherLABOR & INDSTRY RX #
WA51239OtherLABOR & INDSTRY RX #
WA51239OtherLABOR & INDSTRY RX #
WAAW3308574OtherDEA