Provider Demographics
NPI:1922550649
Name:NORDSTROM ACHATZ DENTAL, LLC
Entity Type:Organization
Organization Name:NORDSTROM ACHATZ DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:NORDSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-610-7837
Mailing Address - Street 1:1475 SW CHANDLER AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3240
Mailing Address - Country:US
Mailing Address - Phone:541-610-7837
Mailing Address - Fax:
Practice Address - Street 1:1412 NE 134TH ST STE 120
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-2720
Practice Address - Country:US
Practice Address - Phone:360-573-4848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-28
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60682826122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty