Provider Demographics
NPI:1922203405
Name:SWINOMISH UPPER SKAGIT DENTAL
Entity Type:Organization
Organization Name:SWINOMISH UPPER SKAGIT DENTAL
Other - Org Name:SWINOMISH TRIBAL COMMUNITY
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-466-3900
Mailing Address - Street 1:PO BOX 332
Mailing Address - Street 2:
Mailing Address - City:LA CONNER
Mailing Address - State:WA
Mailing Address - Zip Code:98257-0332
Mailing Address - Country:US
Mailing Address - Phone:360-466-3900
Mailing Address - Fax:360-466-7301
Practice Address - Street 1:17395 RESERVATION RD
Practice Address - Street 2:
Practice Address - City:LA CONNER
Practice Address - State:WA
Practice Address - Zip Code:98257-8802
Practice Address - Country:US
Practice Address - Phone:360-466-3900
Practice Address - Fax:360-466-7301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC64981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5039490Medicaid