Provider Demographics
NPI:1376572511
Name:PENNY C WALPOLE DDS PS
Entity Type:Organization
Organization Name:PENNY C WALPOLE DDS PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:C
Authorized Official - Last Name:WALPOLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS PS
Authorized Official - Phone:509-922-4809
Mailing Address - Street 1:15701 E SPRAGUE AVE
Mailing Address - Street 2:STE F
Mailing Address - City:VERADALE
Mailing Address - State:WA
Mailing Address - Zip Code:99037
Mailing Address - Country:US
Mailing Address - Phone:509-922-4809
Mailing Address - Fax:509-922-8718
Practice Address - Street 1:15701 E SPRAGUE AVE
Practice Address - Street 2:STE F
Practice Address - City:VERADALE
Practice Address - State:WA
Practice Address - Zip Code:99037
Practice Address - Country:US
Practice Address - Phone:509-922-4809
Practice Address - Fax:509-922-8718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE79951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty