Provider Demographics
NPI:1629786603
Name:LITTLE BIG KIDS PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:LITTLE BIG KIDS PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:DORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-765-2255
Mailing Address - Street 1:800 N STRATFORD RD
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-1512
Mailing Address - Country:US
Mailing Address - Phone:509-765-2255
Mailing Address - Fax:
Practice Address - Street 1:3919 CREEKSIDE LOOP
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-4877
Practice Address - Country:US
Practice Address - Phone:509-955-4853
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LITTLE BIG KIDS PEDIATRIC DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2058522Medicaid