=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669691796
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FRANK A. LASLEY IV DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2007
-----------------------------------------------------
Last Update Date | 02/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2405 BORST AVE
-----------------------------------------------------
City | CENTRALIA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98531-1411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-736-0129
-----------------------------------------------------
Fax | 360-330-2074
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 675
-----------------------------------------------------
City | CENTRALIA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98531-0675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-736-0129
-----------------------------------------------------
Fax | 360-736-0129
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DE00010717
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------