Provider Demographics
NPI:1811085665
Name:PACKARD, PACKARD & PACKARD, PS
Entity type:Organization
Organization Name:PACKARD, PACKARD & PACKARD, PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LESLEE
Authorized Official - Middle Name:R
Authorized Official - Last Name:THYSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-577-8277
Mailing Address - Street 1:1501 S 40TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3963
Mailing Address - Country:US
Mailing Address - Phone:509-577-8277
Mailing Address - Fax:509-573-4858
Practice Address - Street 1:1501 S 40TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-3963
Practice Address - Country:US
Practice Address - Phone:509-577-8277
Practice Address - Fax:509-573-4858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6014727261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5020037Medicaid
WA5020037Medicaid