Basic Information
| Provider Information | |||||||||
| NPI: | 1215467667 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH CARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SPANAWAY DENTAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1148 BROADWAY STE 100 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984023518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535974550 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 134 188TH ST S | ||||||||
| Address2: | |||||||||
| City: | SPANAWAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983874618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538472304 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2017 | ||||||||
| LastUpdateDate: | 06/07/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FLENTGE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2535974550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.