Provider Demographics
NPI:1396023164
Name:THOMPSON.FERGUSON.STEINHART.JAMES.LEAVITT, PLLC
Entity Type:Organization
Organization Name:THOMPSON.FERGUSON.STEINHART.JAMES.LEAVITT, PLLC
Other - Org Name:APPLE VALLEY DENTAL AND ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:C
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-823-4480
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:509-823-4480
Mailing Address - Fax:509-823-4488
Practice Address - Street 1:3217 PICARD PL
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-8400
Practice Address - Country:US
Practice Address - Phone:509-790-0722
Practice Address - Fax:509-837-2517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-28
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60170604122300000X
WA60160969122300000X
WA9229122300000X
WA10686122300000X
WA3855122300000X
WA60162008122300000X
WA60102410122300000X
WA60166205122300000X
WA111971223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1091661Medicaid
WA2005801Medicaid
WA2011723Medicaid
WA1010228Medicaid
WA2003693Medicaid
WA2009912Medicaid
WA1054937Medicaid
WA2009645Medicaid
WA2009772Medicaid