Provider Demographics
NPI:1316460421
Name:SCOTT SODERSTROM D D S P C
Entity type:Organization
Organization Name:SCOTT SODERSTROM D D S P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PATIENT ACCOUNTS AND BILLING
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-467-5202
Mailing Address - Street 1:101 W CASCADE WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-6000
Mailing Address - Country:US
Mailing Address - Phone:509-467-5202
Mailing Address - Fax:509-466-0518
Practice Address - Street 1:101 W CASCADE WAY STE 200
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-6000
Practice Address - Country:US
Practice Address - Phone:509-467-5202
Practice Address - Fax:509-466-0518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-20
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5034749Medicaid