Provider Demographics
NPI:1396194338
Name:TRI CITY DENTAL CARE, PLLC
Entity Type:Organization
Organization Name:TRI CITY DENTAL CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ-IBARRA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-579-0759
Mailing Address - Street 1:3711 PLAZA WAY
Mailing Address - Street 2:STE 120
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99338-2718
Mailing Address - Country:US
Mailing Address - Phone:509-579-0759
Mailing Address - Fax:
Practice Address - Street 1:3711 PLAZA WAY
Practice Address - Street 2:STE 120
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99338-2718
Practice Address - Country:US
Practice Address - Phone:509-579-0759
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60487049122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty