Provider Demographics
NPI:1417572892
Name:DEER PARK DENTAL PLLC
Entity Type:Organization
Organization Name:DEER PARK DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:FLETCHER
Authorized Official - Last Name:MONTANO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:786-955-7284
Mailing Address - Street 1:PO BOX 18184
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99228-0184
Mailing Address - Country:US
Mailing Address - Phone:509-850-8061
Mailing Address - Fax:
Practice Address - Street 1:118 E. CRAWFORD ST.
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:WA
Practice Address - Zip Code:99006
Practice Address - Country:US
Practice Address - Phone:509-850-8061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-11
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2085276Medicaid