SQUAXIN ISLAND DENTAL CLINIC ENCOUNTER (SQUAXIN ISLAND TRIBE) - NPI NUMBER 1003021338

Summary

Provider Name: SQUAXIN ISLAND DENTAL CLINIC ENCOUNTER (SQUAXIN ISLAND TRIBE)

NPI Number: 1003021338

Clasification: Clinic/Center (261QD0000X)

Specialization: Dental

Address:
90 SE KLAH CHE MIN DR
SHELTON, WA
ZIP 98584

Phone Number: (360) 427-9006



Detailed Information

SQUAXIN ISLAND DENTAL CLINIC ENCOUNTER is a dental clinic/center in Shelton, WA. The assigned NPI number for this provider is 1003021338 and is registered as an organization entity type.
The provider Other Name Is Squaxin Island Tribe.

The provider's business address is:

90 SE KLAH CHE MIN DR
SHELTON, WA
ZIP 98584-216
Phone: (360) 427-9006

The provider's authorized official is Whitney Jones .
The authorized official title is Director and has the following contact phone number (360) 427-9006.

The enumeration date for this NPI number is 5/11/2007 and was last updated on 7/9/2007.

Map - Location of Practice

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Taxonomy Codes

The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1 261QD0000X Clinic/Center Dental WA Yes

Other (Legacy) Identifiers

The following legacy identifiers are available for this provider:

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
1 5400122 MEDICAID WA

NPI Record

No. Field Name Field Value
1 NPI 1003021338
2 Entity Type Code 2
3 Employer Identification Number EIN
4 Provider Organization Name Legal Business Name SQUAXIN ISLAND DENTAL CLINIC ENCOUNTER
5 Provider Other Organization Name SQUAXIN ISLAND TRIBE
6 Provider Other Organization Name Type Code 5
7 Provider First Line Business Practice Location Address 90 SE KLAH CHE MIN DR
8 Provider Business Practice Location Address City Name SHELTON
9 Provider Business Practice Location Address State Name WA
10 Provider Business Practice Location Address Postal Code 985849216
11 Provider Business Practice Location Address Country Code If outside U S US
12 Provider Business Practice Location Address Telephone Number 3604279006
13 Provider Enumeration Date 5/11/2007
14 Last Update Date 7/9/2007
15 Authorized Official Last Name JONES
16 Authorized Official First Name WHITNEY
17 Authorized Official Title or Position DIRECTOR
18 Authorized Official Telephone Number 3604279006
19 Healthcare Provider Taxonomy Code 1 261QD0000X
20 Provider License Number State Code 1 WA
21 Healthcare Provider Primary Taxonomy Switch 1 Y
22 Other Provider Identifier 1 5400122
23 Other Provider Identifier Type Code 1 05
24 Other Provider Identifier State 1 WA

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This page was last updated on: 10/12/2014
All materials and services on this site are provided on an "as is" and "as available" basis without warranty of any kind. The NPI record is maintained by the National Plan & Provider Enumeration System (NPPES) and anyone may request this information and other NPPES health care provider data from HHS under The Freedom of Information Act (FOIA), Title 5 of the United States Code, section 552. To update the NPI records please contact the NPPES.