Provider Demographics
NPI: | 1417053638 |
---|---|
Name: | JOHN BERWIND DDS PS |
Entity Type: | Organization |
Organization Name: | JOHN BERWIND DDS PS |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | DENTIST-PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JOHN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BERWIND |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS PS |
Authorized Official - Phone: | 360-423-4020 |
Mailing Address - Street 1: | 911 11TH AVE |
Mailing Address - Street 2: | SUITE A |
Mailing Address - City: | LONGVIEW |
Mailing Address - State: | WA |
Mailing Address - Zip Code: | 98632-2547 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 360-423-4020 |
Mailing Address - Fax: | 360-636-1460 |
Practice Address - Street 1: | 911 11TH AVE |
Practice Address - Street 2: | SUITE A |
Practice Address - City: | LONGVIEW |
Practice Address - State: | WA |
Practice Address - Zip Code: | 98632-2547 |
Practice Address - Country: | US |
Practice Address - Phone: | 360-423-4020 |
Practice Address - Fax: | 360-636-1460 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-09-15 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WA | 4319 | 1223G0001X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Single Specialty |