Provider Demographics
NPI:1679642151
Name:CSDENTAL, PLLC
Entity Type:Organization
Organization Name:CSDENTAL, PLLC
Other - Org Name:CREEKSIDE DENTAL KENNEWICK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FLOYD
Authorized Official - Middle Name:L
Authorized Official - Last Name:PACKARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-737-0327
Mailing Address - Street 1:216 N EDISON ST
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-1956
Mailing Address - Country:US
Mailing Address - Phone:509-737-0327
Mailing Address - Fax:509-737-1360
Practice Address - Street 1:216 N EDISON ST
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-1956
Practice Address - Country:US
Practice Address - Phone:509-737-0327
Practice Address - Fax:509-737-1360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5048046Medicaid