Provider Demographics
NPI:1871548925
Name:CONDON DENTAL SERVICES
Entity type:Organization
Organization Name:CONDON DENTAL SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:CONDON
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:509-982-2605
Mailing Address - Street 1:PO BOX 429
Mailing Address - Street 2:20 W FIRST
Mailing Address - City:ODESSA
Mailing Address - State:WA
Mailing Address - Zip Code:99159-0429
Mailing Address - Country:US
Mailing Address - Phone:509-982-2605
Mailing Address - Fax:509-982-9951
Practice Address - Street 1:20 W 1ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:WA
Practice Address - Zip Code:99159-0459
Practice Address - Country:US
Practice Address - Phone:509-982-2605
Practice Address - Fax:509-982-9951
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONDON DENTAL SERVICES, PS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-24
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA84401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5054358Medicaid