Provider Demographics
NPI:1700222197
Name:EVERGREEN DENTAL
Entity Type:Organization
Organization Name:EVERGREEN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:G
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-921-2396
Mailing Address - Street 1:2403 E EVERGREEN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-4320
Mailing Address - Country:US
Mailing Address - Phone:360-696-1671
Mailing Address - Fax:
Practice Address - Street 1:2403 E EVERGREEN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-4320
Practice Address - Country:US
Practice Address - Phone:360-696-1671
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60041682122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty