Provider Demographics
NPI:1932420650
Name:YELM FAMILY DENTISTRY
Entity Type:Organization
Organization Name:YELM FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CLISTA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAKOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-458-1919
Mailing Address - Street 1:PO BOX 5350
Mailing Address - Street 2:
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597-5350
Mailing Address - Country:US
Mailing Address - Phone:360-458-1919
Mailing Address - Fax:
Practice Address - Street 1:106 PLAZA DR SE
Practice Address - Street 2:BLDG A, SUITE 1
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597-8798
Practice Address - Country:US
Practice Address - Phone:360-458-1919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-16
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA73361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5029046OtherSTATE PROVIDER NUMBER