Healthcare Provider Details

I. General information

NPI: 1174617724
Provider Name (Legal Business Name): COLUMBIA ENDODONTIC GROUP, P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5015 NE ST. JOHNS ROAD
VANCOUVER WA
98661
US

IV. Provider business mailing address

5015 NE ST. JOHNS ROAD
VANCOUVER WA
98661
US

V. Phone/Fax

Practice location:
  • Phone: 360-699-1101
  • Fax: 360-695-3152
Mailing address:
  • Phone: 360-699-1101
  • Fax: 360-695-3152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: DAVID AKIO KOSA
Title or Position: TREASURER
Credential: D.D.S.
Phone: 360-699-1101