Provider Demographics
NPI:1598975849
Name:FAIRFIELD DENTAL CLINIC, LLC
Entity Type:Organization
Organization Name:FAIRFIELD DENTAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MARC
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-283-2261
Mailing Address - Street 1:PO BOX 305
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:99012-0305
Mailing Address - Country:US
Mailing Address - Phone:509-283-2261
Mailing Address - Fax:509-283-2261
Practice Address - Street 1:214 E MAIN
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:WA
Practice Address - Zip Code:99012
Practice Address - Country:US
Practice Address - Phone:509-283-2261
Practice Address - Fax:509-283-2261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA030599678OtherTIN