MEDICARE: WEST VANCOUVER DENTAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1083562730
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST VANCOUVER DENTAL LLC

Provider Business Mailing Address
First Line	:	117 E 39TH ST
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98663-2229
Country	:	US
Telephone Number	:	360-694-7931
Fax Number	:	360-694-0722

Provider Business Practice Location Address
First Line	:	117 E 39TH ST
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98663-2229
Country	:	US
Telephone Number	:	360-694-7931
Fax Number	:	360-694-0722

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	JARED HAWTHORNE
Credential	:
Telephone Number	:	360-694-7931

Provider Enumeration Date	:	03/18/2026
Last Update Date	:	03/18/2026

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