Basic Information
| Provider Information | |||||||||
| NPI: | 1245378389 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WHITE SWAN DENTAL CLNIC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | IHS YAKAMA SERVICE UNIT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 693 | ||||||||
| Address2: | |||||||||
| City: | WHITE SWAN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 87841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098652102 | ||||||||
| FaxNumber: | 5098654986 | ||||||||
| Practice Location | |||||||||
| Address1: | 62 BIRD SONG LANE | ||||||||
| Address2: | |||||||||
| City: | WHITE SWAN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098742028 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 08/06/2012 | ||||||||
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| AuthorizedOfficialLastName: | SAMPSON | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5098652102 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WHITE SWAN DENTAL CLINIC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
ID Information
| ID | Type | State | Issuer | Description | 7100506 | 05 | WA | MEDICAID | AW3308574 | 01 | WA | DEA | OTHER | 21940 | 01 | WA | LABOR & INDSTRY MED # | OTHER | 51239 | 01 | WA | LABOR & INDSTRY RX # | OTHER |