Provider Demographics
NPI:1457541021
Name:EASTERN WASHINGTON UNIVERSITY DENTAL HYGIENE
Entity Type:Organization
Organization Name:EASTERN WASHINGTON UNIVERSITY DENTAL HYGIENE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPARTMENT CHAIR
Authorized Official - Prefix:MS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:STOLBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-368-6528
Mailing Address - Street 1:310 N RIVERPOINT BLVD
Mailing Address - Street 2:BOX E
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202
Mailing Address - Country:US
Mailing Address - Phone:509-368-6550
Mailing Address - Fax:509-368-6514
Practice Address - Street 1:310 N RIVERPOINT BLVD
Practice Address - Street 2:BOX E
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202
Practice Address - Country:US
Practice Address - Phone:509-368-6550
Practice Address - Fax:509-368-6514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA48641223G0001X
WA65541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA508205Medicaid