Provider Demographics
NPI:1760655716
Name:CONDON DENTAL SERVICES PS INC
Entity Type:Organization
Organization Name:CONDON DENTAL SERVICES PS INC
Other - Org Name:NORTHWEST DENTAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:CONDON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-926-5272
Mailing Address - Street 1:5901 N LIDGERWOOD
Mailing Address - Street 2:SUITE 233
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208
Mailing Address - Country:US
Mailing Address - Phone:509-489-4763
Mailing Address - Fax:509-489-4767
Practice Address - Street 1:5901 N LIDGERWOOD
Practice Address - Street 2:SUITE 233
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208
Practice Address - Country:US
Practice Address - Phone:509-489-4763
Practice Address - Fax:509-489-4767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5055512Medicaid