Individual
CADEN NGO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.D.S
Contact information
Practice address
3100 SE OLD OLYMPIC HWY, SHELTON, WA 98584-7731
(360) 427-1784
(360) 427-1818
Mailing address
3100 SE OLD OLYMPIC HWY, SHELTON, WA 98584-7731
(360) 427-1784
(360) 427-1818
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
DE00008865
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
122300000X
TAXONOMY
WA
05
—
5041058
—
WA
01
—
DE00008865
DENTIST
WA
Enumeration date
04/19/2007
Last updated
07/09/2007
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