Provider Demographics
NPI:1841202009
Name:FALL CITY DENTAL CLINIC INC
Entity Type:Organization
Organization Name:FALL CITY DENTAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:M
Authorized Official - Last Name:FAWCETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-222-7011
Mailing Address - Street 1:PO BOX 1029
Mailing Address - Street 2:
Mailing Address - City:FALL CITY
Mailing Address - State:WA
Mailing Address - Zip Code:98024
Mailing Address - Country:US
Mailing Address - Phone:425-222-7011
Mailing Address - Fax:425-222-9574
Practice Address - Street 1:33609 REDMOND-FALL CITY RD
Practice Address - Street 2:
Practice Address - City:FALL CITY
Practice Address - State:WA
Practice Address - Zip Code:98024
Practice Address - Country:US
Practice Address - Phone:425-222-7011
Practice Address - Fax:425-222-9574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00005563122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAFA1504OtherREGENCE INS
WA215712215712OtherPREMERA BLUE CROSS
WA674169OtherUNITED CONCORDIA INC