Healthcare Provider Details

I. General information

NPI: 1104093731
Provider Name (Legal Business Name): SWINOMISH/UPPER SKAGIT DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 05/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17395 RESERVATION RD
LA CONNER WA
98257-8802
US

IV. Provider business mailing address

PO BOX 332
LA CONNER WA
98257-0332
US

V. Phone/Fax

Practice location:
  • Phone: 360-466-3900
  • Fax:
Mailing address:
  • Phone: 360-466-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License NumberNC6498
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License NumberNC6498
License Number StateNC

VIII. Authorized Official

Name: DR. RAYMOND A DAILEY
Title or Position: DENTIST
Credential: DDS
Phone: 360-466-3900