Provider Demographics
NPI:1922213289
Name:BRADLEY L DECOUNTER DDS MS LLC
Entity Type:Organization
Organization Name:BRADLEY L DECOUNTER DDS MS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST PROSTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:LON
Authorized Official - Last Name:DECOUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:509-926-7431
Mailing Address - Street 1:826 N MULLAN RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99206
Mailing Address - Country:US
Mailing Address - Phone:509-926-7431
Mailing Address - Fax:509-926-1359
Practice Address - Street 1:826 N MULLAN RD
Practice Address - Street 2:SUITE D
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99206
Practice Address - Country:US
Practice Address - Phone:509-926-7431
Practice Address - Fax:509-926-1359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA59221223G0001X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5096706Medicaid