Healthcare Provider Details

I. General information

NPI: 1669531067
Provider Name (Legal Business Name): PORT GAMBLE S'KLALLAM DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32014 LITTLE BOSTON RD NE
KINGSTON WA
98346-9734
US

IV. Provider business mailing address

32014 LITTLE BOSTON RD NE
KINGSTON WA
98346-9734
US

V. Phone/Fax

Practice location:
  • Phone: 360-297-9601
  • Fax: 360-297-9614
Mailing address:
  • Phone: 360-297-9601
  • Fax: 360-297-9614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KERSTIN MARGARETA POWELL
Title or Position: HEALTH CENTER BUSINESS OFFICE MANAG
Credential:
Phone: 360-297-9601