Provider Demographics
NPI:1265987663
Name:SOUTH HILL FAMILY DENTAL
Entity type:Organization
Organization Name:SOUTH HILL FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:R
Authorized Official - Last Name:CRAVEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-747-7166
Mailing Address - Street 1:1424 S BERNARD ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203-5008
Mailing Address - Country:US
Mailing Address - Phone:509-747-7166
Mailing Address - Fax:509-747-0483
Practice Address - Street 1:1424 S BERNARD ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99203-5008
Practice Address - Country:US
Practice Address - Phone:509-747-7166
Practice Address - Fax:509-747-0483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00010773261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1003288Medicaid