=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053661777
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCDONALD DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2012
-----------------------------------------------------
Last Update Date | 09/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1205 HARRISON AVE NW
-----------------------------------------------------
City | OLYMPIA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98502-5494
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-352-4008
-----------------------------------------------------
Fax | 360-534-0479
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1205 HARRISON AVE NW
-----------------------------------------------------
City | OLYMPIA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98502-5494
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-352-4008
-----------------------------------------------------
Fax | 360-534-0479
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BRADY CLARKE MCDONALD
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 360-352-4008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 10554
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------