Provider Demographics
NPI:1689195836
Name:CASCADE MEDICAL AND DENTAL LLC
Entity type:Organization
Organization Name:CASCADE MEDICAL AND DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:TIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:206-818-0769
Mailing Address - Street 1:807 S DOGWOOD CT
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-7564
Mailing Address - Country:US
Mailing Address - Phone:206-818-0769
Mailing Address - Fax:
Practice Address - Street 1:410 MACON AVE
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-3225
Practice Address - Country:US
Practice Address - Phone:719-276-0117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00010745261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental