Provider Demographics
NPI:1740434125
Name:MEYERS-FOLSOM DENTAL CLINIC
Entity type:Organization
Organization Name:MEYERS-FOLSOM DENTAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:CARI
Authorized Official - Middle Name:E
Authorized Official - Last Name:MEYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-758-5011
Mailing Address - Street 1:1336 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-3314
Mailing Address - Country:US
Mailing Address - Phone:509-758-5011
Mailing Address - Fax:509-751-9125
Practice Address - Street 1:1336 5TH ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-3314
Practice Address - Country:US
Practice Address - Phone:509-758-5011
Practice Address - Fax:509-751-9125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-11
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00005292122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5007018Medicaid
WA5021787Medicaid
WADE00007440OtherSTATE LICENSE NUMBER
WADE60882146OtherSTATE LICENSE NUMBER
WADE00005292OtherSTATE LICENSE NUMBER
WA5000146Medicaid