1497077986 NPI number — BRUCE C TOILLION

Table of content: (NPI 1497077986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497077986 NPI number — BRUCE C TOILLION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRUCE C TOILLION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MEDICAL LAKE DENTAL
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497077986
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDICAL LAKE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99022-0010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-299-5171
Provider Business Mailing Address Fax Number:
509-299-5151

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
N 123 BROWER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDICAL LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-299-5171
Provider Business Practice Location Address Fax Number:
509-299-5151
Provider Enumeration Date:
02/24/2010

Additional Information

Authorized Official

Authorized Official Last Name:
TOILLION
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER/DDS
Authorized Official Telephone Number:
509-299-5171

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  4735 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5511704 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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