Basic Information
| Provider Information | |||||||||
| NPI: | 1891913042 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBIA BASIN HEALTH ASSOCIATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | OTHELLO DENTAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 E COLUMBIA ST | ||||||||
| Address2: | |||||||||
| City: | OTHELLO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993441846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094885256 | ||||||||
| FaxNumber: | 5094889939 | ||||||||
| Practice Location | |||||||||
| Address1: | 1515 E COLUMBIA ST | ||||||||
| Address2: | |||||||||
| City: | OTHELLO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993441846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094885256 | ||||||||
| FaxNumber: | 5094889939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 09/03/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BUNCH | ||||||||
| AuthorizedOfficialFirstName: | JOSHUA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5094885250 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COLUMBIA BASIN HEALTH ASSOCIATION | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | WA | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QF0400X | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 0134585 | 01 | WA | DEPT L&I # | OTHER | 1021671 | 05 | WA | MEDICAID | 8923240 | 01 | WA | CRIME VICTIMS # | OTHER |