Provider Demographics
NPI:1942589908
Name:THOMPSON.FERGUSON.STEINHART.JAMES.LEAVITT,PLLC
Entity Type:Organization
Organization Name:THOMPSON.FERGUSON.STEINHART.JAMES.LEAVITT,PLLC
Other - Org Name:APPLE VALLEY DENTAL AND ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:509-823-4480
Mailing Address - Street 1:4309 W NOB HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3971
Mailing Address - Country:US
Mailing Address - Phone:509-823-4480
Mailing Address - Fax:509-823-4488
Practice Address - Street 1:3217 PICARD PL
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-8400
Practice Address - Country:US
Practice Address - Phone:509-790-0722
Practice Address - Fax:509-837-2517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-09
Last Update Date:2012-03-12
Deactivation Date:2011-09-23
Deactivation Code:
Reactivation Date:2012-03-12
Provider Licenses
StateLicense IDTaxonomies
WADE 601873651223X0400X
WA111971223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1091661Medicaid
WA2010061Medicaid