Provider Demographics
NPI:1750835849
Name:MACK, LINDSAY
Entity Type:Individual
Prefix:
First Name:LINDSAY
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:LINDSAY
Other - Middle Name:A
Other - Last Name:KELSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1721 E LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-2478
Mailing Address - Country:US
Mailing Address - Phone:509-837-7178
Mailing Address - Fax:509-837-3117
Practice Address - Street 1:1721 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-2478
Practice Address - Country:US
Practice Address - Phone:509-837-7178
Practice Address - Fax:509-837-3117
Is Sole Proprietor?:No
Enumeration Date:2016-08-07
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60657452122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist