Provider Demographics
NPI:1720535297
Name:NEWPORT DENTAL
Entity Type:Organization
Organization Name:NEWPORT DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:COOL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:509-447-3105
Mailing Address - Street 1:610 WEST SECOND ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:WA
Mailing Address - Zip Code:99156
Mailing Address - Country:US
Mailing Address - Phone:509-447-3105
Mailing Address - Fax:509-447-5661
Practice Address - Street 1:610 WEST SECOND ST.
Practice Address - Street 2:BOX 849
Practice Address - City:NEWPORT
Practice Address - State:WA
Practice Address - Zip Code:99156
Practice Address - Country:US
Practice Address - Phone:509-447-3105
Practice Address - Fax:509-447-5661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA5239261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1376625442Medicaid