NPIMap

Organization Active NPI

Kalispel Tribe of Indians

Doing business as Camas Center Dental Clinic

  • Dentist
  • Cusick, WA
National Provider Identifier
1083980080
Registry record updated Sep 13, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
License
DE00009801 Issued in WA
Legal business name
KALISPEL TRIBE OF INDIANS
Doing business as
Camas Center Dental Clinic
Practice address
1821 Leclerc Rd N Ste 1
Cusick, WA 99119-5015
Phone
(509) 447-7111
Fax
(509) 445-1152
NPI assigned
Mar 24, 2012
Last updated
Sep 13, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 13, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Tracy Lynn Birdtail
Title
Am
Phone
(509) 447-7112

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dentist 122300000X DE00009801 WA Primary

Addresses

Primary practice location

1821 Leclerc Rd N Ste 1
Cusick, WA 99119-5015

Mailing address

PO Box 67
Usk, WA 99180-0067
Phone (509) 447-7111

Other identifiers 1

IdentifierTypeStateIssuer
5051537MedicaidWA

Other names 1

  • Camas Center Dental Clinic Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Kalispel Indian Community of the Kalispel Reservation Washington4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1332547200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1694563200000",
    "number": "1083980080",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 67",
            "city": "USK",
            "state": "WA",
            "postal_code": "991800067",
            "telephone_number": "509-447-7111",
            "fax_number": "509-445-1152"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1821 LECLERC RD N STE 1",
            "city": "CUSICK",
            "state": "WA",
            "postal_code": "991195015",
            "telephone_number": "509-447-7111",
            "fax_number": "509-445-1152"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KALISPEL TRIBE OF INDIANS",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-03-24",
        "last_updated": "2023-09-13",
        "certification_date": "2023-09-13",
        "status": "A",
        "authorized_official_last_name": "BIRDTAIL",
        "authorized_official_first_name": "TRACY",
        "authorized_official_middle_name": "LYNN",
        "authorized_official_title_or_position": "AM",
        "authorized_official_telephone_number": "509-447-7112"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "WA",
            "license": "DE00009801",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5051537",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Camas Center Dental Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Camas Center Dental Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Cusick, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 13, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.