Provider Demographics
NPI:1588117568
Name:SALMON CREEK FAMILY DENTAL
Entity type:Organization
Organization Name:SALMON CREEK FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:DONALDSON
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:360-696-9461
Mailing Address - Street 1:2515 NE 134TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-3041
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:360-699-7199
Practice Address - Street 1:2515 NE 134TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-3041
Practice Address - Country:US
Practice Address - Phone:360-696-9461
Practice Address - Fax:360-699-7199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00006928261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5034020Medicaid