Provider Demographics
NPI:1184284689
Name:WALLA WALLA ORTHODONTICS
Entity type:Organization
Organization Name:WALLA WALLA ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:CREWSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-525-7030
Mailing Address - Street 1:1608 PENNY LN
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4477
Mailing Address - Country:US
Mailing Address - Phone:509-525-7030
Mailing Address - Fax:509-522-3704
Practice Address - Street 1:1608 PENNY LN
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4477
Practice Address - Country:US
Practice Address - Phone:509-525-7030
Practice Address - Fax:509-522-3704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty