Provider Demographics
NPI:1689696734
Name:GOLDENDALE DENTAL CENTER INC PC
Entity Type:Organization
Organization Name:GOLDENDALE DENTAL CENTER INC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LYLE
Authorized Official - Middle Name:E
Authorized Official - Last Name:FERCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-773-5545
Mailing Address - Street 1:617 EAST COLLINS DR
Mailing Address - Street 2:
Mailing Address - City:GOLDENDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98620
Mailing Address - Country:US
Mailing Address - Phone:509-773-5545
Mailing Address - Fax:509-773-6718
Practice Address - Street 1:617 E COLLINS ST
Practice Address - Street 2:
Practice Address - City:GOLDENDALE
Practice Address - State:WA
Practice Address - Zip Code:98620-9213
Practice Address - Country:US
Practice Address - Phone:509-773-5545
Practice Address - Fax:509-773-6718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000065891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0105783OtherL&I PROVIDER #
WA5013024Medicaid