Provider Demographics
NPI:1376764233
Name:DEREK THOMPSON DMD PATRICK FERGUSON DDS
Entity Type:Organization
Organization Name:DEREK THOMPSON DMD PATRICK FERGUSON DDS
Other - Org Name:APPLE VALLEY DENTAL AND ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MEADOWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-457-6300
Mailing Address - Street 1:2100 S 14TH ST
Mailing Address - Street 2:
Mailing Address - City:UNION GAP
Mailing Address - State:WA
Mailing Address - Zip Code:98903-1252
Mailing Address - Country:US
Mailing Address - Phone:509-457-6300
Mailing Address - Fax:
Practice Address - Street 1:2100 S 14TH ST
Practice Address - Street 2:
Practice Address - City:UNION GAP
Practice Address - State:WA
Practice Address - Zip Code:98903-1252
Practice Address - Country:US
Practice Address - Phone:509-457-6300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00009229122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5038799Medicaid
WA5043641Medicaid