Provider Demographics
NPI:1891843769
Name:NOOKSACK DENTAL CLINIC
Entity Type:Organization
Organization Name:NOOKSACK DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:CDA
Authorized Official - Phone:360-306-5151
Mailing Address - Street 1:6760 MISSION RD
Mailing Address - Street 2:
Mailing Address - City:EVERSON
Mailing Address - State:WA
Mailing Address - Zip Code:98247-9749
Mailing Address - Country:US
Mailing Address - Phone:360-306-5151
Mailing Address - Fax:360-306-5191
Practice Address - Street 1:6760 MISSION RD
Practice Address - Street 2:
Practice Address - City:EVERSON
Practice Address - State:WA
Practice Address - Zip Code:98247-9749
Practice Address - Country:US
Practice Address - Phone:360-306-5151
Practice Address - Fax:360-306-5191
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NOOKSACK TRIBE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-08
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00010128122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty