Provider Demographics
NPI:1407176993
Name:TRI-STAR DENTURE CLINIC
Entity Type:Organization
Organization Name:TRI-STAR DENTURE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTURIST
Authorized Official - Prefix:MR
Authorized Official - First Name:LENARD
Authorized Official - Middle Name:GOBIN
Authorized Official - Last Name:DEOCHAND
Authorized Official - Suffix:
Authorized Official - Credentials:LD, DD
Authorized Official - Phone:360-906-0015
Mailing Address - Street 1:2802 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-2220
Mailing Address - Country:US
Mailing Address - Phone:360-906-0015
Mailing Address - Fax:360-906-0023
Practice Address - Street 1:2802 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-2220
Practice Address - Country:US
Practice Address - Phone:360-906-0015
Practice Address - Fax:360-906-0023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-07
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA00008442122300000X
WADN00000394122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278500Medicaid
WA5047667Medicaid