Healthcare Provider Details

I. General information

NPI: 1164089934
Provider Name (Legal Business Name): TRI-CITY ORTHODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2019
Last Update Date: 05/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 DUPORTAIL ST, STE 203
RICHLAND WA
99352
US

IV. Provider business mailing address

3200 DUPORTAIL ST, STE 203
RICHLAND WA
99352
US

V. Phone/Fax

Practice location:
  • Phone: 509-946-7689
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN COLLETTE
Title or Position: OWNER
Credential: DDS
Phone: 509-366-6882