| NPI | 1548814262 |
|---|---|
| Doing Business As | COLLEGE AVE MODERN DENTAL |
| Entity Type | Organization |
| Authorized Contact | MICHELLE JOHNSON Credentialing Specialist 509-315-8338 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice |
| Enumeration Date | 2019-07-31 |
| Last Update Date | 2019-07-31 |