# CLARK COUNTY DENTAL & DENTURE CLINIC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1962423129
- **Authorized official:** SALLY IRENE FETTIG (BUSINESS MANAGER)
- **Authorized official phone:** (360) 892-7107

## Contact information

- **Practice address:** 2701 NE 114TH AVE, \# K-6, VANCOUVER, WA 98684-4289
- **Practice address phone:** (360) 892-7107
- **Practice address fax:** (360) 891-8361
- **Mailing address:** 2701 NE 114TH AVE, \# K-6, VANCOUVER, WA 98684-4289
- **Mailing address phone:** (360) 892-7107
- **Mailing address fax:** (360) 891-8361

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | DE00008735 | WA | Yes |

## Other

- **Enumeration date:** 07/22/2006
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 5026356 | — | WA |
| 05 | — | 5036074 | — | WA |
| 05 | — | 5041082 | — | WA |
| 05 | — | 5047576 | — | WA |
| 05 | — | 5048616 | — | WA |