Basic Information
| Provider Information | |||||||||
| NPI: | 1780826479 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GADD | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 230 WASHINGTON WAY | ||||||||
| Address2: | |||||||||
| City: | CENTRALIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985319325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607365405 | ||||||||
| FaxNumber: | 3607365620 | ||||||||
| Practice Location | |||||||||
| Address1: | 711 HARRISON AVE | ||||||||
| Address2: | |||||||||
| City: | CENTRALIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985312109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607365405 | ||||||||
| FaxNumber: | 3607365620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2009 | ||||||||
| LastUpdateDate: | 03/27/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DE00005252 | WA | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 5050489 | 05 | WA | MEDICAID |