Provider Demographics
NPI:1447380233
Name:WEST PASCO FAMILY DENTAL LLC
Entity Type:Organization
Organization Name:WEST PASCO FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:W
Authorized Official - Last Name:FRODEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-547-9955
Mailing Address - Street 1:5204 N ROAD 68
Mailing Address - Street 2:SUITE B
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-9275
Mailing Address - Country:US
Mailing Address - Phone:509-547-9955
Mailing Address - Fax:509-544-2827
Practice Address - Street 1:5204 N ROAD 68
Practice Address - Street 2:SUITE B
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-9275
Practice Address - Country:US
Practice Address - Phone:509-547-9955
Practice Address - Fax:509-544-2827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA55671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5050190Medicaid