Basic Information
Provider Information | |||||||||
NPI: | 1134779408 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LAMONDIN | ||||||||
FirstName: | COURTNEY | ||||||||
MiddleName: | I | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | JOINT BASE LEWIS-MCCHORD DENTAC | ||||||||
Address2: | 9900 LINCOLN STREET 2ND FLOOR | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 98431 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2539684079 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 11582 C STREET | ||||||||
Address2: |   | ||||||||
City: | JOINT BASE LEWIS-MCCHORD | ||||||||
State: | WA | ||||||||
PostalCode: | 98431 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2539661991 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/18/2019 | ||||||||
LastUpdateDate: | 09/18/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | D11158 | OR | Y |   | Dental Providers | Dentist | General Practice |
ID Information
ID | Type | State | Issuer | Description | D11158 | 01 | OR | DENTAL LICENSE | OTHER |