Provider Demographics
NPI:1700283058
Name:DOWNTOWN DENTAL ON 4TH LLC
Entity type:Organization
Organization Name:DOWNTOWN DENTAL ON 4TH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LANDRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-540-0347
Mailing Address - Street 1:730 SE 8TH ST
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:99324-1646
Mailing Address - Country:US
Mailing Address - Phone:509-540-0347
Mailing Address - Fax:
Practice Address - Street 1:1320 N 4TH AVE STE A
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-3711
Practice Address - Country:US
Practice Address - Phone:509-540-0347
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-02
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA107881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty