Provider Demographics
NPI:1912226127
Name:ANGUS SQUARE DENTAL
Entity Type:Organization
Organization Name:ANGUS SQUARE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:HARKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-783-4194
Mailing Address - Street 1:407 N CONWAY ST
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-3047
Mailing Address - Country:US
Mailing Address - Phone:509-783-4194
Mailing Address - Fax:509-735-2196
Practice Address - Street 1:407 N CONWAY ST
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-3047
Practice Address - Country:US
Practice Address - Phone:509-783-4194
Practice Address - Fax:509-735-2196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-27
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA9911122300000X
WA10931122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty