MEDICARE: SCOTT SODERSTROM D D S P C

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	261QD0000X	Dental Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316460421
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SCOTT SODERSTROM D D S P C

Provider Business Mailing Address
First Line	:	101 W CASCADE WAY STE 200
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99208-6000
Country	:	US
Telephone Number	:	509-467-5202
Fax Number	:	509-466-0518

Provider Business Practice Location Address
First Line	:	101 W CASCADE WAY STE 200
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99208-6000
Country	:	US
Telephone Number	:	509-467-5202
Fax Number	:	509-466-0518

Authorized Official
Title or Position	:	PATIENT ACCOUNTS AND BILLING
Name	:	TRACY JOHNSON
Credential	:
Telephone Number	:	509-467-5202

Provider Enumeration Date	:	07/20/2017
Last Update Date	:	03/06/2023

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Directions to “SCOTT SODERSTROM D D S P C ” Practice Location

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