Provider Demographics
NPI:1477006831
Name:NW AFFINITY DENTAL
Entity Type:Organization
Organization Name:NW AFFINITY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHAUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-253-3500
Mailing Address - Street 1:19120 SE 34TH ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-1429
Mailing Address - Country:US
Mailing Address - Phone:360-253-3500
Mailing Address - Fax:360-823-0267
Practice Address - Street 1:19120 SE 34TH ST
Practice Address - Street 2:SUITE 104
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-1429
Practice Address - Country:US
Practice Address - Phone:360-253-3500
Practice Address - Fax:360-823-0267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00011060122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty