NPIMap

Organization Active NPI

Custom Dentures LLC

  • Denturist
  • Vancouver, WA
National Provider Identifier
1093965600
Registry record updated Sep 19, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
DenturistTaxonomy code 122400000X
License
DN00000393 Issued in WA
Legal business name
CUSTOM DENTURES LLC
Practice address
13720 NE 28TH St
#B
Vancouver, WA 98682-8048
Phone
(360) 883-9888
Fax
(360) 883-9909
NPI assigned
Sep 19, 2008
Last updated
Sep 19, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 19, 2008

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

Authorized official

Name
Cameron L. Fettig
Title
Business Manager
Phone
(360) 883-9888

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
DenturistGroup: 193400000X SINGLE SPECIALTY GROUP 122400000X DN00000393 WA Primary

Addresses

Primary practice location

13720 NE 28TH St
#B
Vancouver, WA 98682-8048

Mailing address

13720 NE 28TH St
#B
Vancouver, WA 98682-8048
Phone (360) 883-9888

Other identifiers 1

IdentifierTypeStateIssuer
5047576MedicaidWA

National Provider Directory

National Provider Directory

Locations

13720 NE 28th St
#B
Vancouver, WA 98682
Phone (360) 883-9888

NPI Registry JSON

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

{
    "created_epoch": "1221782400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1221782400000",
    "number": "1093965600",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "13720 NE 28TH ST",
            "address_2": "#B",
            "city": "VANCOUVER",
            "state": "WA",
            "postal_code": "986828048",
            "telephone_number": "360-883-9888",
            "fax_number": "360-883-9909"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "13720 NE 28TH ST",
            "address_2": "#B",
            "city": "VANCOUVER",
            "state": "WA",
            "postal_code": "986828048",
            "telephone_number": "360-883-9888",
            "fax_number": "360-883-9909"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CUSTOM DENTURES LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-09-19",
        "last_updated": "2008-09-19",
        "status": "A",
        "authorized_official_last_name": "FETTIG",
        "authorized_official_first_name": "CAMERON",
        "authorized_official_middle_name": "L.",
        "authorized_official_title_or_position": "BUSINESS MANAGER",
        "authorized_official_telephone_number": "360-883-9888"
    },
    "taxonomies": [
        {
            "code": "122400000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Denturist",
            "state": "WA",
            "license": "DN00000393",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5047576",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Vancouver, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 19, 2008; 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.