Basic Information
| Provider Information | |||||||||
| NPI: | 1790977965 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONFEDERATED TRIBES & BANDS OF THE YAKAMA NATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 BIRDSONG LANE | ||||||||
| Address2: | |||||||||
| City: | WHITE SWAN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098655121 | ||||||||
| FaxNumber: | 5098742113 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 BUSTER RD | ||||||||
| Address2: | |||||||||
| City: | TOPPENISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989489792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098652102 | ||||||||
| FaxNumber: | 5098658995 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2007 | ||||||||
| LastUpdateDate: | 07/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | SWAN | ||||||||
| AuthorizedOfficialFirstName: | ELLEN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5098655121 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | N | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dental Hygienist | 261QD0000X | DS-091445-L | PA | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
ID Information
| ID | Type | State | Issuer | Description | 5400171 | 05 | WA | MEDICAID |