Provider Demographics
NPI:1265793129
Name:CARNELL FAMILY DENTISTRY
Entity type:Organization
Organization Name:CARNELL FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:CARNELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PS
Authorized Official - Phone:509-326-8120
Mailing Address - Street 1:4610 N ASH ST STE 204
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-1482
Mailing Address - Country:US
Mailing Address - Phone:509-326-8120
Mailing Address - Fax:509-325-5370
Practice Address - Street 1:4610 N ASH ST STE 204
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-1482
Practice Address - Country:US
Practice Address - Phone:509-326-8120
Practice Address - Fax:509-325-5370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000027971223G0001X, 261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty