Basic Information
| Provider Information | |||||||||
| NPI: | 1972700284 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRI-CITIES COMMUNITY HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1452 | ||||||||
| Address2: | |||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095472204 | ||||||||
| FaxNumber: | 5095428836 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 W COURT ST | ||||||||
| Address2: | |||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095472204 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2007 | ||||||||
| LastUpdateDate: | 06/28/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CARDOZA | ||||||||
| AuthorizedOfficialFirstName: | MONICA | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL STAFF SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 5095431920 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0300X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Periodontics | 1223P0700X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Prosthodontics | 124Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dental Hygienist | 126800000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dental Assistant | 126900000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dental Laboratory Technician | 1223G0001X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 122300000X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 5015854 | 05 | WA | MEDICAID |