Basic Information
Provider Information | |||||||||
NPI: | 1942717079 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WASHINGTON DENTAL CORPORATION, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MARYSVILLE MODERN DENTISTRY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 17000 RED HILL AVE | ||||||||
Address2: |   | ||||||||
City: | IRVINE | ||||||||
State: | CA | ||||||||
PostalCode: | 926145626 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7148458500 | ||||||||
FaxNumber: | 3039520892 | ||||||||
Practice Location | |||||||||
Address1: | 8820 36TH AVE NE STE 103 | ||||||||
Address2: |   | ||||||||
City: | MARYSVILLE | ||||||||
State: | WA | ||||||||
PostalCode: | 982707268 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3607183098 | ||||||||
FaxNumber: | 3607183138 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/10/2018 | ||||||||
LastUpdateDate: | 01/10/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCGLASHAN | ||||||||
AuthorizedOfficialFirstName: | WILLIAM | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER DENTIST | ||||||||
AuthorizedOfficialTelephone: | 3607183098 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DDS | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.