Provider Demographics
NPI:1821456419
Name:COLUMBIA EBJ LLC
Entity Type:Organization
Organization Name:COLUMBIA EBJ LLC
Other - Org Name:EXCEL DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLIS
Authorized Official - Middle Name:BURKE
Authorized Official - Last Name:JARDINE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-862-3185
Mailing Address - Street 1:1401 NW 1ST ST
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-4540
Mailing Address - Country:US
Mailing Address - Phone:360-666-5700
Mailing Address - Fax:360-666-5701
Practice Address - Street 1:1401 NW 1ST ST
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-4540
Practice Address - Country:US
Practice Address - Phone:360-666-5700
Practice Address - Fax:360-666-5701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA122300000X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FJ5060897OtherDEA