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2353 Lower Green Canyon Rd Ellensburg WA 98926-8514 | |
| (509) 607-1872 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Clinic/center - Dental |
| Location | 2353 Lower Green Canyon Rd, Ellensburg, Washington |
| Authorized Official Name and Position | Brenden J Davis (CEO) |
| Authorized Official Contact | 5096071872 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
2353 Lower Green Canyon Rd Ellensburg WA 98926-8514 Ph: (509) 607-1872 | 2353 Lower Green Canyon Rd Ellensburg WA 98926-8514 Ph: (509) 607-1872 |
| NPI Number | 1629445929 |
|---|---|
| Provider Enumeration Date | 08/21/2015 |
| Last Update Date | 08/21/2015 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1629445929 | NPI | - | NPPES |
| 0255549 | Other | WA | LABOR & INDUSTRIES |
| 5060215 | Medicaid | WA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QD0000X | Clinic/center - Dental | 603513887 (Washington) | Primary |
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