Provider Demographics
NPI:1649786484
Name:ESKILDSEN, TIAH CHRISTINE
Entity type:Individual
Prefix:
First Name:TIAH
Middle Name:CHRISTINE
Last Name:ESKILDSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1614 SE RED OAK AVE
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:99324-1791
Mailing Address - Country:US
Mailing Address - Phone:509-876-9746
Mailing Address - Fax:
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:509-280-9020
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA100439516WAMedicaid