Provider Demographics
NPI:1801837463
Name:ADVANCED DENTURE & IMPLANT, INC
Entity Type:Organization
Organization Name:ADVANCED DENTURE & IMPLANT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:YVONNE
Authorized Official - Last Name:GOLDSBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-260-0122
Mailing Address - Street 1:3705 NE 154TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-7418
Mailing Address - Country:US
Mailing Address - Phone:360-882-4884
Mailing Address - Fax:360-882-7588
Practice Address - Street 1:14602 NE 4TH PLAIN RD
Practice Address - Street 2:SUITE G
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98682
Practice Address - Country:US
Practice Address - Phone:360-882-4884
Practice Address - Fax:360-882-7588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN0130122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5045372Medicaid