MEDICARE: CARNELL FAMILY DENTISTRY

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	DE00002797	WA
2	261QD0000X	Dental Clinic/Center	DE00002797	WA

General Provider Information

NPI Number	:	1265793129
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARNELL FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	4610 N ASH ST STE 204
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99205-1482
Country	:	US
Telephone Number	:	509-326-8120
Fax Number	:	509-325-5370

Provider Business Practice Location Address
First Line	:	4610 N ASH ST STE 204
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99205-1482
Country	:	US
Telephone Number	:	509-326-8120
Fax Number	:	509-325-5370

Authorized Official
Title or Position	:	DENTIST
Name	:	VICTOR CARNELL
Credential	:	DDS, PS
Telephone Number	:	509-326-8120

Provider Enumeration Date	:	06/06/2012
Last Update Date	:	06/06/2012

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Directions to “CARNELL FAMILY DENTISTRY ” Practice Location

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