Provider Demographics
NPI:1740618925
Name:DEREK THOMPSON DMD PATRICK FERGUSON DDS PLLC
Entity Type:Organization
Organization Name:DEREK THOMPSON DMD PATRICK FERGUSON DDS PLLC
Other - Org Name:YAKIMA FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGOTTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-823-4481
Mailing Address - Street 1:4309 W NOB HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3971
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2100 S 14TH ST
Practice Address - Street 2:
Practice Address - City:UNION GAP
Practice Address - State:WA
Practice Address - Zip Code:98903-1252
Practice Address - Country:US
Practice Address - Phone:509-457-6300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-24
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000090451223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2012717Medicaid