Provider Demographics
NPI:1407925456
Name:AUSTIN FAMILY DENTISTRY PLLC
Entity Type:Organization
Organization Name:AUSTIN FAMILY DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-882-1647
Mailing Address - Street 1:2100 SE 164TH AVE
Mailing Address - Street 2:#D102
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683
Mailing Address - Country:US
Mailing Address - Phone:360-882-1647
Mailing Address - Fax:360-882-1446
Practice Address - Street 1:2100 SE 164TH AVE
Practice Address - Street 2:#D102
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683
Practice Address - Country:US
Practice Address - Phone:360-882-1647
Practice Address - Fax:360-882-1446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE8705122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
999320OtherUNITED CONCORDIA TRICARE