Provider Demographics
NPI:1821162033
Name:STILLAGUAMISH TRIBE OF INDIANS
Entity Type:Organization
Organization Name:STILLAGUAMISH TRIBE OF INDIANS
Other - Org Name:STILLAGUAMISH FAMILY DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:TATRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-403-8761
Mailing Address - Street 1:430 N WEST AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ARLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98223-1539
Mailing Address - Country:US
Mailing Address - Phone:360-403-8761
Mailing Address - Fax:360-474-9085
Practice Address - Street 1:430 N WEST AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223-1539
Practice Address - Country:US
Practice Address - Phone:360-403-8761
Practice Address - Fax:360-474-9085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5049770Medicaid