Provider Demographics
NPI:1063553014
Name:KETCHERS' DENTAL PLLC
Entity type:Organization
Organization Name:KETCHERS' DENTAL PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:J
Authorized Official - Last Name:KETCHER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:360-426-8401
Mailing Address - Street 1:1829 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-2004
Mailing Address - Country:US
Mailing Address - Phone:360-426-8401
Mailing Address - Fax:360-426-1427
Practice Address - Street 1:1829 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2004
Practice Address - Country:US
Practice Address - Phone:360-426-8401
Practice Address - Fax:360-426-1427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE97091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty