Provider Demographics
NPI:1457326878
Name:SODERSTROM, SCOTT (D D S P C)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:
Last Name:SODERSTROM
Suffix:
Gender:M
Credentials:D D S P C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W CASCADE WAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-6003
Mailing Address - Country:US
Mailing Address - Phone:509-467-5202
Mailing Address - Fax:509-468-0518
Practice Address - Street 1:101 W CASCADE WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-6003
Practice Address - Country:US
Practice Address - Phone:509-467-5202
Practice Address - Fax:509-466-0518
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-20
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000086681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5037479Medicaid
WADE00008668OtherSTATE DENTAL LICENSE
WA21933OtherUNITED CONCORDIA ID
WA602-040-560OtherUNIFIED BUSINESS ID
1287SOOtherBLUE CROSS
WA0150532OtherLABOR AND INDUSTRIES ID#
174980063OtherADA NUMBER
91-2051287OtherTAX ID #