=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811629413
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT GORDON THURESON DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2022
-----------------------------------------------------
Last Update Date | 06/30/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 708 E MOUNTAIN VIEW AVE
-----------------------------------------------------
City | ELLENSBURG
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98926-3862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-962-2755
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 708 E MOUNTAIN VIEW AVE
-----------------------------------------------------
City | ELLENSBURG
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98926-3862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DE61324476
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------