NPIMap

Organization Active NPI

Clark County Dental & Denture Clinic

  • General Practice Dentistry
  • Vancouver, WA
National Provider Identifier
1962423129
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
License
DE00008735 Issued in WA
Legal business name
CLARK COUNTY DENTAL & DENTURE CLINIC
Practice address
2701 NE 114TH Ave
# K-6
Vancouver, WA 98684-4289
Phone
(360) 892-7107
Fax
(360) 891-8361
NPI assigned
Jul 22, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

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

Authorized official

Name
Sally Irene Fettig
Title
Business Manager
Phone
(360) 892-7107

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193200000X MULTI-SPECIALTY GROUP 1223G0001X DE00008735 WA Primary

Addresses

Primary practice location

2701 NE 114TH Ave
# K-6
Vancouver, WA 98684-4289

Mailing address

2701 NE 114TH Ave
# K-6
Vancouver, WA 98684-4289
Phone (360) 892-7107

Other identifiers 5

IdentifierTypeStateIssuer
5036074MedicaidWA
5041082MedicaidWA
5026356MedicaidWA
5048616MedicaidWA
5047576MedicaidWA

National Provider Directory

National Provider Directory
Tax ID family
Clark County Dental Denture Clinic2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

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

Locations

2701 NE 114th Ave
#K6
Vancouver, WA 98684
Phone (360) 892-7107

NPI Registry JSON

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

{
    "created_epoch": "1153526400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1962423129",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2701 NE 114TH AVE",
            "address_2": "# K-6",
            "city": "VANCOUVER",
            "state": "WA",
            "postal_code": "986844289",
            "telephone_number": "360-892-7107",
            "fax_number": "360-891-8361"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2701 NE 114TH AVE",
            "address_2": "# K-6",
            "city": "VANCOUVER",
            "state": "WA",
            "postal_code": "986844289",
            "telephone_number": "360-892-7107",
            "fax_number": "360-891-8361"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CLARK COUNTY DENTAL & DENTURE CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-22",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "FETTIG",
        "authorized_official_first_name": "SALLY",
        "authorized_official_middle_name": "IRENE",
        "authorized_official_title_or_position": "BUSINESS MANAGER",
        "authorized_official_telephone_number": "360-892-7107"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": "WA",
            "license": "DE00008735",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5036074",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5041082",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5026356",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5048616",
            "state": "WA"
        },
        {
            "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 Aug 22, 2020; 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.