Provider Demographics
NPI:1477630507
Name:JAMESTOWN S'KLALLAM TRIBE
Entity Type:Organization
Organization Name:JAMESTOWN S'KLALLAM TRIBE
Other - Org Name:JAMESTOWN DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TRIBAL CHAIRMAN/EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:W.
Authorized Official - Middle Name:RON
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-683-1109
Mailing Address - Street 1:1033 OLD BLYN HWY
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-7670
Mailing Address - Country:US
Mailing Address - Phone:360-683-1109
Mailing Address - Fax:360-683-3401
Practice Address - Street 1:1033 OLD BLYN HWY
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-7670
Practice Address - Country:US
Practice Address - Phone:360-683-1109
Practice Address - Fax:360-683-3401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, FederalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7123433Medicaid