Basic Information
| Provider Information | |||||||||
| NPI: | 1720590920 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMERON | ||||||||
| FirstName: | DANE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9900 LINCOLN ST | ||||||||
| Address2: | 2ND FLOOR, ATTN: CREDENTIALS | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539684079 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9119 MIL PARK AVE | ||||||||
| Address2: | FULTON DENTAL | ||||||||
| City: | JBLM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539669960 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2017 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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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 | 124Q00000X | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | 1454810640 | 01 | US ARMY | OTHER |