Provider Demographics
NPI:1679648539
Name:FUNK, JODI W (DDS)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:W
Last Name:FUNK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2829 S GRAND BLVD
Mailing Address - Street 2:STE: 301
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203
Mailing Address - Country:US
Mailing Address - Phone:509-747-4242
Mailing Address - Fax:509-747-3512
Practice Address - Street 1:2829 S GRAND BLVD
Practice Address - Street 2:STE 301
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99203
Practice Address - Country:US
Practice Address - Phone:509-747-4242
Practice Address - Fax:509-747-3512
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00001693122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5031091OtherDEPT OF SOCIAL & HEALTH
WA5031091OtherDEPT OF SOCIAL & HEALTH