Provider Demographics
NPI:1437313616
Name:ENDODONTICS OF SOUTHEASTERN WA, PLLC
Entity type:Organization
Organization Name:ENDODONTICS OF SOUTHEASTERN WA, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:K
Authorized Official - Last Name:BASCOM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-735-9735
Mailing Address - Street 1:10505 W CLEARWATER AVE
Mailing Address - Street 2:BLDG. A
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-8613
Mailing Address - Country:US
Mailing Address - Phone:509-735-9735
Mailing Address - Fax:509-735-9598
Practice Address - Street 1:10505 W CLEARWATER AVE
Practice Address - Street 2:BLDG. A
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-8613
Practice Address - Country:US
Practice Address - Phone:509-735-9735
Practice Address - Fax:509-735-9598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA88421223E0200X
WA104811223E0200X
WA73501223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1164582722OtherJAMES E. LEONARD, DDS
1245390996OtherLINDA K. BASCOM, DDS
1386692556OtherROLF M.W. WUERCH, DDS