Healthcare Provider Details

I. General information

NPI: 1871548925
Provider Name (Legal Business Name): CONDON DENTAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 11/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 W 1ST
ODESSA WA
99159-0459
US

IV. Provider business mailing address

PO BOX 429 20 W FIRST
ODESSA WA
99159-0429
US

V. Phone/Fax

Practice location:
  • Phone: 509-982-2605
  • Fax: 509-982-9951
Mailing address:
  • Phone: 509-982-2605
  • Fax: 509-982-9951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8440
License Number StateWA

VIII. Authorized Official

Name: MICHAEL P CONDON
Title or Position: OWNER
Credential: DR
Phone: 509-982-2605