Provider Demographics
NPI:1215685599
Name:RIVER DISTRICT MODERN DENTISTRY PLLC
Entity type:Organization
Organization Name:RIVER DISTRICT MODERN DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADLE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:509-408-5080
Mailing Address - Street 1:21808 E INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-4004
Mailing Address - Country:US
Mailing Address - Phone:509-408-5080
Mailing Address - Fax:509-461-0403
Practice Address - Street 1:21808 E INDIANA AVE
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-4004
Practice Address - Country:US
Practice Address - Phone:509-408-5080
Practice Address - Fax:509-461-0403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental