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General NPI Number Information
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NPI Number | 1629445929
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Entity Type | Organization
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Legal Business Name | NORTHWEST ORAL HEALTH OUTREACH LLC
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Dates
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Enumeration Date | 08/21/2015
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Last Update Date | 08/21/2015
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Provider Practice Location Address
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Address Line | 2353 LOWER GREEN CANYON RD
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City | ELLENSBURG
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State | WA
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Zip | 98926-8514
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Country | US
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Telephone | 509-607-1872
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Fax |
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Provider Business Mailing Address
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Address Line | 2353 LOWER GREEN CANYON RD
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City | ELLENSBURG
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State | WA
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Zip | 98926-8514
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Country | US
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Telephone | 509-607-1872
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. BRENDEN J DAVIS
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Credential | DMD, MPH
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Telephone | 509-607-1872
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 603513887
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License Number State | WA
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