Provider Demographics
NPI:1497796130
Name:EVERGREEN COSMETIC & FAMILY DENTISTRY
Entity Type:Organization
Organization Name:EVERGREEN COSMETIC & FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:SINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-928-4191
Mailing Address - Street 1:1005 N EVERGREEN RD
Mailing Address - Street 2:SUITE #202
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-1485
Mailing Address - Country:US
Mailing Address - Phone:509-928-4191
Mailing Address - Fax:509-921-5942
Practice Address - Street 1:1005 N EVERGREEN RD
Practice Address - Street 2:SUITE #202
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1485
Practice Address - Country:US
Practice Address - Phone:509-928-4191
Practice Address - Fax:509-921-5942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty