Provider Demographics
NPI:1063616985
Name:FORT VANCOUVER DENTAL CENTRE
Entity type:Organization
Organization Name:FORT VANCOUVER DENTAL CENTRE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:SWAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-256-2400
Mailing Address - Street 1:718 NE 87TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-1970
Mailing Address - Country:US
Mailing Address - Phone:360-256-2400
Mailing Address - Fax:360-253-9123
Practice Address - Street 1:718 NE 87TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-1970
Practice Address - Country:US
Practice Address - Phone:360-256-2400
Practice Address - Fax:360-253-9123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5262209Medicaid