Provider Demographics
NPI:1265683189
Name:DEREK THOMPSON DMD PATRICK FERGUSON DDS, PLLC
Entity Type:Organization
Organization Name:DEREK THOMPSON DMD PATRICK FERGUSON DDS, PLLC
Other - Org Name:APPLE VALLEY DENTAL & ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTENR
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:C
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:509-457-6300
Mailing Address - Street 1:4309 W NOB HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3971
Mailing Address - Country:US
Mailing Address - Phone:509-457-6300
Mailing Address - Fax:509-248-7438
Practice Address - Street 1:4309 W NOB HILL BLVD
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-3971
Practice Address - Country:US
Practice Address - Phone:509-457-6300
Practice Address - Fax:509-248-7438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA9229122300000X
WA10686122300000X
WA8036122300000X
WA3855122300000X
122300000X
WA111971223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1548480072Medicaid
WA1982822904Medicaid
WA1427185826Medicaid
WA1376763813Medicaid
WA1407045875Medicaid