Basic Information
| Provider Information | |||||||||
| NPI: | 1548628175 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOUMA | ||||||||
| FirstName: | TYLER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6950 NE CAMPUS WAY | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971245611 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9019 E MISSION AVE | ||||||||
| Address2: | SPOKANE VALLEY OFFICE | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554336825 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2016 | ||||||||
| LastUpdateDate: | 07/13/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | RR 60559973 | WA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1223G0001X | DE60660643 | WA | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 54456158 | 01 | WA | DENTPIN | OTHER |