Basic Information
| Provider Information | |||||||||
| NPI: | 1841518859 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPAVINAWDENTAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2201 E EDISON RD STE 2 | ||||||||
| Address2: | |||||||||
| City: | SUNNYSIDE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989449214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098373090 | ||||||||
| FaxNumber: | 5098373414 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 E EDISON RD STE 2 | ||||||||
| Address2: | 1726 GREGORY AVE. BOX 314 | ||||||||
| City: | SUNNYSIDE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989449214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098373090 | ||||||||
| FaxNumber: | 5098373414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2010 | ||||||||
| LastUpdateDate: | 05/14/2010 | ||||||||
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| AuthorizedOfficialLastName: | NORELL | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | JOHN | ||||||||
| AuthorizedOfficialTitleorPosition: | DENTIST | ||||||||
| AuthorizedOfficialTelephone: | 5098373090 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | 7925 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
ID Information
| ID | Type | State | Issuer | Description | 5052469 | 05 | WA | MEDICAID |