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Provider Information for 1619369972

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1619369972

Calendar   Last Updated:  2019-02-20
  Certification Date: 


Name Value
NPI 1619369972
Enumeration Date 2015-02-24
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 140 E MAIN ST
OTHELLO, WA 99344-1040
United States

Phone: 509-488-5256 | Fax: 509-488-9939
View Map External Link
Primary Practice Address 670 NE 3RD ST
PRINEVILLE, OR 97754-2021
United States

Phone: 541-447-3855 | Fax:
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 122300000X - Dentist OR D10997
No 122300000X - Dentist WA RR60482579