Healthcare Provider Details

I. General information

NPI: 1407176993
Provider Name (Legal Business Name): TRI-STAR DENTURE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2010
Last Update Date: 06/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2802 COLUMBIA ST
VANCOUVER WA
98660-2220
US

IV. Provider business mailing address

2802 COLUMBIA ST
VANCOUVER WA
98660-2220
US

V. Phone/Fax

Practice location:
  • Phone: 360-906-0015
  • Fax: 360-906-0023
Mailing address:
  • Phone: 360-906-0015
  • Fax: 360-906-0023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberWA00008442
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberDN00000394
License Number StateWA

VIII. Authorized Official

Name: MR. LENARD GOBIN DEOCHAND
Title or Position: DENTURIST
Credential: LD, DD
Phone: 360-906-0015