Provider Demographics
NPI:1679728711
Name:A CHILDREN'S DENTIST
Entity Type:Organization
Organization Name:A CHILDREN'S DENTIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CONWAY
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-666-0530
Mailing Address - Street 1:1215 SW SCOTTON WAY STE 130
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-2700
Mailing Address - Country:US
Mailing Address - Phone:360-666-0530
Mailing Address - Fax:360-666-9144
Practice Address - Street 1:1215 SW SCOTTON WAY STE 130
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-2700
Practice Address - Country:US
Practice Address - Phone:360-666-0530
Practice Address - Fax:360-666-9144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-17
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000106701223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty