Basic Information
| Provider Information | |||||||||
| NPI: | 1023134988 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOWER ELWHA KLALLAM TRIBE DENTAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 243511 W HIGHWAY 101 | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983639472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604526252 | ||||||||
| FaxNumber: | 3604526274 | ||||||||
| Practice Location | |||||||||
| Address1: | 243511 W HIGHWAY 101 | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983639472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604526252 | ||||||||
| FaxNumber: | 3604526274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 03/17/2022 | ||||||||
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| AuthorizedOfficialLastName: | CHARLES | ||||||||
| AuthorizedOfficialFirstName: | FRANCES | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRWOMAN | ||||||||
| AuthorizedOfficialTelephone: | 3604528471 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.