Provider Demographics
NPI:1538487665
Name:CLARKSTON DENTURIST CLINIC
Entity Type:Organization
Organization Name:CLARKSTON DENTURIST CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ELDRED
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:LD
Authorized Official - Phone:509-758-7805
Mailing Address - Street 1:1346 12TH ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-2821
Mailing Address - Country:US
Mailing Address - Phone:509-758-7805
Mailing Address - Fax:509-751-1510
Practice Address - Street 1:1346 12TH ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2821
Practice Address - Country:US
Practice Address - Phone:509-758-7805
Practice Address - Fax:509-751-1510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-13
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1003977091Medicaid