| Tietan Dental Team | |
|
1602 Penny Ln Walla Walla WA 99362-4477 | |
| (509) 522-0940 | |
| (509) 525-9063 |
| Full Name | Tietan Dental Team |
|---|---|
| Speciality | Dentist |
| Location | 1602 Penny Ln, Walla Walla, Washington |
| Authorized Official Name and Position | Don R Kellogg (SECRETARY) |
| Authorized Official Contact | 5095220940 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Tietan Dental Team 1602 Penny Ln Walla Walla WA 99362-4477 Ph: (509) 522-0940 | Tietan Dental Team 1602 Penny Ln Walla Walla WA 99362-4477 Ph: (509) 522-0940 |
| NPI Number | 1912124637 |
|---|---|
| Provider Enumeration Date | 04/20/2007 |
| Last Update Date | 05/31/2013 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1912124637 | NPI | - | NPPES |
| 5023346 | Medicaid | WA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | DE00004225 (Washington) | Primary |
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