Provider Demographics
NPI:1982628939
Name:CLARK COUNTY DENTAL & DENTURE CLINIC
Entity Type:Organization
Organization Name:CLARK COUNTY DENTAL & DENTURE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:FETTIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-892-7107
Mailing Address - Street 1:2701 NE 114TH AVE
Mailing Address - Street 2:# K-6
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-4289
Mailing Address - Country:US
Mailing Address - Phone:360-892-7107
Mailing Address - Fax:360-891-8361
Practice Address - Street 1:2701 NE 114TH AVE
Practice Address - Street 2:# K-6
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-4289
Practice Address - Country:US
Practice Address - Phone:360-892-7107
Practice Address - Fax:360-891-8361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN0000195122400000X
WADN00000393122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5047576Medicaid
WA5041082Medicaid
WA5048616Medicaid
WA5036074Medicaid
WA5026356Medicaid