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General NPI Number Information
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NPI Number | 1740630342
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Entity Type | Organization
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Legal Business Name | HOUSE, LEE, MAST, MCDONALD AND NELSON, PC
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Dates
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Enumeration Date | 06/15/2016
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Last Update Date | 08/19/2020
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Provider Practice Location Address
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Address Line | 107 E CHERRY ST
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City | WALLA WALLA
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State | WA
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Zip | 99362-1912
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Country | US
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Telephone | 509-525-7336
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Fax |
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Provider Business Mailing Address
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Address Line | 107 E CHERRY ST
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City | WALLA WALLA
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State | WA
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Zip | 99362-1912
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Country | US
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Telephone | 509-525-7336
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Fax |
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Authorized Official
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Title or Position | REGIONAL OPERATIONS MANAGER
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Name | MELLISSA RENNER
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Credential |
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Telephone | 541-667-4145
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | DE60203055
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License Number State | WA
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